Get Newborn Enrollment Notification Report - Anthem

Completing the Newborn Enrollment Notification Report is essential for ensuring that a newborn is promptly added to an eligible mother’s Anthem plan. This guide will walk you through the necessary steps to effectively fill out the form online.

Follow the steps to complete your enrollment notification.

1. Click ‘Get Form’ button to obtain the Newborn Enrollment Notification Report and open it in your preferred document editor.
2. Begin by entering the date faxed to the county department of job and family services, which is required for tracking submission.
3. Fill in the mother's details, including the mother's effective date, Medicaid ID number (required), social security number, full name (last, first, middle), and date of birth (both are required).
4. Provide the mother's residential address including street, county, city, state, and ZIP code.
5. If known, enter the newborn Medicaid ID number and the newborn’s full name as well (last, first, middle); this field is required.
6. For multiple births, provide the names of additional babies as needed (e.g., Twin Name for Baby 2, 3, etc.).
7. Input the area code and phone number for contact purposes.
8. Specify the gender of the newborn, which is a required field.
9. Enter the newborn’s date of birth; this is another required field.
10. Provide the name of the newborn’s primary care physician (PCP) and the delivery hospital name, both of which are required.
11. Complete the contact name field, which is necessary for follow-up communications. Include the contact's phone number and fax number as well.
12. After filling in all required fields, review the information for accuracy. Save your changes, and you may choose to download, print, or share the completed form as needed.

Ensure your newborn’s enrollment is completed online today!