Patient & Insurance Information

Patient name is required
Date of birth is required

Provider Codes Reference:

MB - 155 834 6098 | AF - 167 906 1196 | HK - 106 391 6138

Pregnancy Information

Insurance Details

Insurance Options:

Next Plan Year Insurance Information

These values are used when EDD or specific procedures fall in the next calendar year

Payment Method Selection by Procedure:

Confirmation Visit:
Sonograms (FTS, 20-Week):
Global OB:
Legend:
• Copay: Fixed copay amount applies
• Co-Ins: Coinsurance percentage applies
• CI/AD: Coinsurance Applied to Deductible
• Bill Insurance First: No upfront patient responsibility, bill insurance directly

Billing Options:

Note: Enable for patients with 100% coverage on certain procedures. When enabled, covered services will show $0 patient responsibility and insurance will be billed first instead of collecting upfront payment.

Insurance Allowable Rates (Auto-populated)

Note: These rates auto-populate based on your insurance selection but can be manually edited if needed.

Current Plan Year Deductible Info

Calculated Results

Remaining Deductible
$0.00
Remaining Out-of-Pocket
$0.00
Confirmation Visit
$0.00
FTS (First Trimester Screen)
$0.00
Separate charge if selected
20 Week Ultrasound
$0.00
Separate charge if selected
Estimated Patient Responsibility
$0.00
Global + ($350 Circumcision - If Applicable)

Enter 28-week date to calculate payment schedule

This is an estimate. Final billing depends on actual services and insurance processing.