Maternity Insurance Dual Coverage Coordination of Benefits (COB) Form
Member Information
Member Name
Member ID
Date of Birth
Phone Number
Address
Other Insurance Information
Is patient covered by another insurance?
Yes
No
Other Insurance Company
Policy Number
Group Number
Effective Date
Policyholder Name
Relationship to Patient
Policyholder Date of Birth
Employer Information
Employer Name
Employer Address
Dependent Information (if applicable)
Name
Date of Birth
Relationship
Covered by Other Insurance
Yes
No
Yes
No
Maternity Details
Expected Delivery Date
Obstetrician/Provider Name
Authorization
Signature
Date