Get 072605 Newborn Hospital Form - Final.doc

Filling out the 072605 Newborn Hospital Form online is a straightforward process that ensures timely notification to health authorities following a child's birth. This guide provides clear and concise instructions to help you navigate each part of the form effectively.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling out the date of notification and the hospital name along with the telephone number and contact person's name in the designated fields.
3. Indicate whether the newborn was delivered at the facility by selecting yes or no, and provide the facility provider number if applicable.
4. Add the admission and discharge dates of the newborn child in the respective fields.
5. Document the name of the attending provider and confirm whether they accept health insurance as primary, with Medicaid as secondary, by marking yes or no.
6. Indicate if the newborn was discharged to another facility and, if so, provide the name and contact number of that facility.
7. Fill out the section for the mother by providing their name, date of birth, social security number, mailing address, and city, state, and zip code information. Indicate whether the mother is covered by Medicaid.
8. Complete the father's section with the same type of information as the mother, including their name, date of birth, mailing address, and details of insurance coverage.
9. In the newborn section, enter the name as it will appear on the birth certificate, along with the birth date, time, weight, race, and sex. Specify if it is a single or multiple birth and if the newborn requires NICU or is adopted.
10. Complete the health insurance sections, detailing the primary and secondary plans if applicable. Include necessary information about the insurance company, group number, member number, and whether the mother is the employee, dependent spouse, or policyholder.
11. Finally, ensure any additional information regarding subsequent newborns is filled out as needed, and review all provided information for accuracy.
12. Once you have completed the form, you can choose to save changes, download, print, or share the completed document.

Start filling out the 072605 Newborn Hospital Form online today to ensure proper notification and benefits for your newborn.