New Patient Registration

Thank you for registering with Tree of Life Birth & Gynecology. Please complete the form in its entirity in order to assure proper insurance billing and estimated out of pocket expenses to you. We will review Financials with you at your next appointment.

Client Information:


SingleMarried


HomeBirth Center


YesNo



Complete Maternity CarePrenatal Care OnlyWell Women CareFamily Planning



Spouses Information:

Not Applicable


YesNo


Policy Holder's Information:

SelfSpouseOther


Insurance Information:




Additional Information: If you have made special arrangements with your insurance company such as receiving permission to see a provider who is normally not covered in your plan, or if you have received a prior authorization #, precertification #, or have a contact person whom we may call if necessary please let us know in the space provided.

Privacy & Assignment Statement:
I authorize the release of any medical or other information necessary to process my claims within the guidelines set forth by HIPPA. I hereby authorize payment directly to the Midwife listed above. I understand that I am financially responsible for charges not covered by my insurance company, my deductible, any co-payments, or co-insurance. I have received and read my providers privacy policy. I understand that currently Tree of Life Birth & Gynecology, LLC is not a participating provider with any insurance company, therefore the services will apply to my Out Of Network Benefits, unless my insurance company provides me with an exception.

Agree:

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