Parents
Welcome
Sources
Claim Processing
Calling Insurance
Glossary
Midwives
What We Offer
Our Clients
Your Clients
Form Library
Resources | FAQs
About | Contact
Parents
Welcome
Sources
Claim Processing
Calling Insurance
Glossary
Midwives
What We Offer
Our Clients
Your Clients
Form Library
Resources | FAQs
About | Contact
GLOBAL BIRTH FORM
Use this form to submit childbirth information to Clearbill.
Midwife Code
*
If you've forgotten your unique midwife code,
contact us
Client Name
*
First Name
Last Name
Trimester
Third
Second
First
Weeks of Gestation
Birth Location
Home
Office
Hospital (enter name below)
Hospital (if applicable)
Date of Delivery
MM
DD
YYYY
Sex of Newborn
Girl
Boy
Newborn Weight
Newborn APGAR
Labor Transfer?
No
Yes (provide details below)
Reason for transfer?
Please provide Dx codes OR descriptions.
DX CODE
V22.0 -- Supervision of Normal First Pregnancy
V22.1 -- Supervision of Normal Other Pregnancy (not first child)
NEWBORN CARE AT DELIVERY (SAME DATE)
Note: If Newborn Services require special Dx codes or were provided on a day OTHER than the delivery date, please bill on a separate ‘Newborn’ claim form
Birth Assist
Initial Exam
Resuscitation
DeLee
NB Venip Heel, Finger
NB Venip Chord Blood
Vitamin K
Additional Comments
Thank you for your form submission
