LABOR FORM

Use this form to submit labor information to Clearbill.

Midwife Code

If you've forgotten your unique midwife code, contact us

Client Name

First Name

Last Name

Trimester

Weeks of Gestation

Date of Delivery

YYYY

Labor Management – Day One

Labor Location

Hospital (if applicable)

Diagnostic Code 1

Diagnostic Code 2

Diagnostic Code 3

Diagnostic Code 4

Unsure? Describe the problem:

Total Hours at This Location on DOS

Cannot exceed 24 hours

Multiple Day Labor? If so, complete the section below for up to 2 consecutive days . Otherwise, Scroll to submit.

Labor Management – Day Two

Date

YYYY

Labor Location

Hospital (if applicable)

Diagnostic Code 1

Diagnostic Code 2

Diagnostic Code 3

Diagnostic Code 4

Unsure? Describe the problem:

Total Hours at This Location on DOS

Cannot exceed 24 hours

Labor Management – Day Three

Date

YYYY

Labor Location

Hospital (if applicable)

Diagnostic Code 1

Diagnostic Code 2

Diagnostic Code 3

Diagnostic Code 4

Unsure? Describe the problem:

Total Hours at This Location on DOS

Cannot exceed 24 hours

Last

Bill for “Transport to Hospital”

If "Yes", please provide date

Yes

Transport Date (if applicable)

YYYY

Additional Comments

LABOR FORM

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