State Of Ca Pregnancy Verification PDF Details

In order to ensure that pregnant women in California are able to get the care they need, the state requires all women to provide verification of their pregnancy status. The form used for this purpose is known as the State of CA Pregnancy Verification Form. This form can be used to verify a woman's pregnancy status for a variety of purposes, including applying for public assistance or enrolling in health insurance. In order to complete the form, you will need some basic information about yourself and your pregnancy. Let's take a closer look at what is required on the State of CA Pregnancy Verification Form.

Here is the details about the form you were in search of to fill in. It will tell you the length of time you will need to complete state of ca pregnancy verification, exactly what parts you need to fill in, and so forth.

QuestionAnswer
Form NameState Of Ca Pregnancy Verification
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespregnancy verification california form, authorization pregnancy verification, pregnancy verification california, confirmation pregnancy form

Form Preview Example

Placement

Education

Support

Community

Record Release Authorization and Pregnancy Verification

Please have your doctor or clinic fill out the appropriate sections and then sign all three copies in the presence of your doctor or clinic. Return one copy to Pact, keep one for your records and leave one for your clinic or doctor. This form allows us to talk to your clinic or doctor about the medical aspects of the pregnancy and/or the medical condition of your child.

Patient’s Name

Doctor’s Name

Address

Telephone

Contact person

Clinic Name

Address

Telephone

Contact person

Hospital Name

Address

Telephone

Contact person

Proof of Pregnancy

Date this form was completed

Pregnancy has been verified

[ ] yes[ ] no

Expected delivery date

month day year

Authorized Signature (include title)

pact, an adoption alliance

4179 Piedmont Avenue, Suite 101, Oakland, CA 94611

Telephone 510.243.9460 Facsimile 510.243.9970

birth parents 800.750.7590

email info@pactadopt.org

www.pactadopt.org

Beth Hall, Director

Prenatal medical record release

I, ______________________________________, hereby authorize the release of any and

all information and/or records relating to my care including history, diagnosis, reports, treatments, labs, or x-rays in your possession while a patient at your facility to Pact: An Adoption Alliance, the adoptive parents, and the adoptive parents’ physician.

_______________________________________

____________

Patient’s Signature

Date

Child’s Record Release Authorization

I, ___________________________________________________, being the parent of

name of birth parent

_______________________________________ a minor child born on

name of child as it appears on birth certificate

____________________________,

date and time of birth

do hereby authorize the release of any and all of the records relating to the care of said child, including history, diagnosis, reports, treatments, labs, or x-rays in your possession while a patient at your facility to Pact: An Adoption Alliance, the adoptive parents, and the adoptive parents’ physician.

____________________________________

_________________

Parent’s Signature

Date

pact, an adoption alliance

4179 Piedmont Avenue, Suite 101, Oakland, CA 94611

Telephone 510.243.9460 Facsimile 510.243.9970

birth parents 800.750.7590

email info@pactadopt.org

www.pactadopt.org

Beth Hall, Director

Watch State Of Ca Pregnancy Verification Video Instruction

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