Roots Billing
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Contact
Home
Contact
Roots Billing
Contact Us
P: 541 815 4336
F: 541 833 0041
For a Verification of your health insurance benefits, please fill out the form below. Roots Billing will email an explanation of your benefits within 3-5 business days.
Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
*
(###)
###
####
Due Date
MM
DD
YYYY
Midwifery Practice Name
Desired Place of Birth
Home
Birth Center
Primary Insurance
Insurance Phone # for Providers
(###)
###
####
Subscriber's Name
First Name
Last Name
Subscriber's Sex
Female
Male
Subscriber's Date of Birth
MM
DD
YYYY
ID # on Card
Group # on Card
Client's Relationship to Subscriber
Self
Spouse
Child
Other
Secondary Insurance
Insurance Phone # for Providers
(###)
###
####
Subscriber's Name
First Name
Last Name
Subscriber's Sex
Female
Male
Subscriber's Date of Birth
MM
DD
YYYY
ID # on Card
Group # on Card
Client Relationship to Subscriber
Self
Spouse
Child
Other
Message
Thank you for your inquiry! I will email you your verificaion in 3-5 business days.