Payment Options - United Black Birth Collective

Insurance

in-network in the state of Virginia

Your Name

Relationship to client

Client Name

Client Date of Birth

Please double check the year month and date for accuracy

Insurance Company

Client Email Address

Client Mobile Number

Preferred follow-up method (choose one)

Member ID/Subscriber ID

Group Number

Insurance Company Phone Number

Client Home Address

Address listed with your insurance company

Client Zip Code

How did you hear about us? What website or person can we thank?

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