Bhsf Newborn Request Form PDF Details

did you know that bhsf offers a newborn request form? if you are expecting or have recently had a baby, this form allows you to request items from the bhsf lending closet to help with your little one's arrival. just visit our website and click on the "newborn" link to access the form. once you have completed it, we will send you an email with information on how to pick up your items. we hope that this service will make life a little bit easier for new families in our community. thanks for considering bhsf as a resource!

QuestionAnswer
Form NameBhsf Newborn Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
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BHSF Newborn Request Form

Rev. 10/06

Prior Issue Obsolete

DEPARTMENT OF HEALTH AND HOSPITALS

MEDICAID PROGRAM

Request for Newborn Medicaid ID Number

(Please Type or Print Legibly)

PART I (To be completed by Hospital)

Mother’s Name ________________________________________________Mother’s Medicaid No.

 

 

 

 

 

 

 

 

 

 

 

(13-digit Medicaid Person Number)

 

Date of Admission

 

Mother’s D.O.B.

 

 

 

Soc. Sec. No.

 

 

 

 

 

Mailing Address

 

 

City

 

 

 

 

State

 

Zip Code

 

 

Parish of Residence

 

 

 

 

 

Phone (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART II (To be completed after the child’s birth. Only enter information for providers that are able to bill Medicaid for the Newborn.)

Newborn’s Name

 

 

 

 

 

 

 

 

 

First Name, Middle Initial (if applicable), Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Newborn’s Sex M

 

F

D.O.B.

 

 

 

 

 

 

 

 

 

 

Newborn’s Race

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Notes:

Twin A

Twin B

NICU

 

 

Adoption – Date of Mother’s Discharge:

 

 

Expired – Date of Death:

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corrected Copy (What is being corrected?):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital Name

 

 

 

 

 

 

 

 

 

 

 

Phone (

)

 

 

Fax

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

Baby’s Attending Physician

 

 

 

 

 

 

 

 

Phone (

)

 

Fax

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

Baby’s Pediatrician

 

 

 

 

 

 

 

 

 

 

 

Phone (

)

 

 

Fax

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

Baby’s Other Provider

 

 

 

 

 

 

 

Phone (

)

 

Fax

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

Baby’s Other Provider

 

 

 

 

 

 

 

Phone (

)

 

Fax

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

Upon release from the hospital, will the newborn live with the mother?

Yes

 

 

No

Has an application been made for a Social Security Number?

 

 

Yes

 

 

No

Does the mother of the newborn have private health insurance coverage?

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Facility Representative

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

Date

PART III (To be completed by BHSF)

Newborn is Medicaid Eligible

Newborn is NOT Medicaid Eligible

Newborn’s Medicaid Person Number

Effective Date of Eligibility

BHSF Representative Signature

 

 

Date

Phone (

)

 

 

 

 

 

 

 

 

 

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