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Release for Filing Health Insurance & Patient Responsibility
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* Indicates required question
Mother's Full Name as appears on insurance card:
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Your answer
Mother's Date of Birth
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MM
/
DD
/
YYYY
Baby's Full Name as appears on insurance card:
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Your answer
Baby's Date of Birth
MM
/
DD
/
YYYY
Date of filling out this form:
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MM
/
DD
/
YYYY
I give my permission for Lake Norman Breastfeeding Solutions to submit claims to my health insurance, on my behalf for payment of lactation consults. I release my private health information to be shared with my health insurance.
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Yes
No
Insurance Provider:
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Your answer
Mother's Relationship to Subscriber
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Self
Spouse
Child
Other adult
Is this you and your baby's primary insurance?
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Yes - mother's primary insurance
Yes - baby's primary insurance
Not mother's primary insurance
Not baby's primary insurance
Required
Insurance Member ID for mother:
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Your answer
Insurance Member ID for baby:
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Your answer
Please list below number of lactation consults or classes you've had already filed with insurance with this pregnancy/baby: (This helps us determine eligibility has some insurers limit number of consults/classes).
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Your answer
We are in-network with Aetna and most families with Aetna are able to receive lactation care without cost sharing (deductibles or co-pays), however, this is ultimately at the discretion of the health insurer and not the healthcare provider.
If my insurance claim is rejected, Lake Norman Breastfeeding Solutions will appeal the claim one time. If it is denied again, I agree to pay the difference between the claim payout and self pay rates. I understand that even if Lake Norman Breastfeeding Solutions is in-network with my insurance provider that I may still be responsible for portions of the cost that my insurance applies to deductible or co-pays.
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Yes
No
My credit card or HSA card number will be kept on file and I give permission for it to be charged if the claim is denied after appeal or for any balances my insurance deems patient responsibility.
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Yes
No
Name on Credit Card (or HSA):
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Your answer
Credit Card (or HSA) Number:
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Your answer
Credit Card Expiration Date:
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Your answer
Credit Card Security Code:
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Your answer
Credit Card Billing Zipcode:
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Your answer
Please type your full name as authorization of your e-signature for all billing policies and information shared in this form:
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Your answer
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