Best Way Medical Billing Patient Registration Form

Provider name
First name
Last name
Address
City
State
Zip
Home Phone
Cell Phone
Email
Social Security
General Care
Name of provider for this verification
Birthday

MonthDayYear
Date
Due Date

MonthDayYear
Date
LMP

MonthDayYear
Date
Would you like Best Way Medical Billing to verify your benefits?
First Pregnancy?
Type of delivery
Place of service
Primary Insurance Company
Primary Insurance Company
Plan Name
Effective Date

MonthDayYear
Date
Insurance ID
Insurance Group
Insurance Address
City
State
Zip
Insurance Phone
Insurance Policy Holder Name
Relationship to Insurance Policy Holder
Birthday

MonthDayYear
Date
Sex
Social Security
Employer
File Upload

front insurance card and back insurance card
Cancelof
Secondary Insurance Company
Plan Name
Effective Date

MonthDayYear
Date
Insurance ID
Insurance Group
Insurance Address
City
State
Zip
Insurance Phone
Insurance Policy Holder Name
Relationship to Insurance Policy Holder
Birthday

MonthDayYear
Date
Sex
Social Security
Employer
File Upload

front insurance card and back insurance card
Cancelof
Do you have more then 2 insurances
If yes please add in the field the same information for additional insurance
File Upload

front insurance card and back insurance card
Cancelof
I certify that the information on this form is correct to the best of my knowledge. By signing this form, I authorize Best Way Medical Billing (BWMB) to verify my primary insurance benefits and charge me the fee of $25. I authorize secondary insurance benefits to be verified for an additional fee of $10 if necessary.
Best Way Medical Billing specifically DISCLAIMS LIABILITY FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES and assumes no responsibility or liability for any loss or damage suffered by any person as a result of the use or misuse of any of the information or content included in this Verification of Benefits report. Best Way Medical Billing assumes or undertakes NO LIABILITY for any loss or damage suffered as a result of the use, misuse or reliance on the information and content on the Verification of Benefits report or findings.

In the case of gross negligence or willful misconduct, the liability of Best Way Medical Billing to any patient seeking Verification of Benefits services is limited to the cost of the verification ($25.00) under this agreement. Verifications that are performed at no cost to the patient carry zero liability.
Type a question
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Email

My Products

Verification of Benefits

to verify your insurance for medical services you are receiving for reimbursement by insurance

$25.00

Additional Insurances Verification

If you have more then one insurance you need to click on this if its more then one add as many to verify all

$10.00 Quantity

Authorization for in network exception

if you have a HMO or are looking for your insurance to pay at the in network level

$50.00

Authorization for other services

if you insurance requires authorization for payment regardless of network

$20.00

Medicaid Out of Network Authorization

Service Fee for obtain authorization for medicaid insurance for your out of network provider.

$10.00

Superbill creation

for clients with Christian Medi-share, Samartian or Christian Health Ministries, liberty healthshare any insurance requiring superbill for reimbursement

$25.00

Enter coupon

Total

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

Email
example@example.com
Signature
Should be Empty: