Loading
Get Newborn Referral Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Newborn Referral Form online
The Newborn Referral Form is an essential document for assisting a Medi-Cal eligible parent in reporting the birth of their child to Medi-Cal. Completing this form accurately ensures that the newborn can start receiving necessary Medi-Cal services as soon as possible.
Follow the steps to complete the Newborn Referral Form online.
- Press the ‘Get Form’ button to access the Newborn Referral Form. This will open the form in your document editor of choice.
- Begin with Section A, where you will enter the mother’s information. Provide the mother’s full name, date of birth, and either the Benefits Identification Card (BIC) number or Social Security Number (SSN). Fill in the mailing address, city, county, state, ZIP code, and telephone number.
- Proceed to Section B. Enter the newborn's full name, date of birth, and select the gender. If there are multiple newborns, repeat these steps for each one, providing their details.
- In this section, you can optionally provide a BIC number for each newborn. For organizational purposes, include the place of birth — this can be a hospital or clinic name along with the address, if available.
- Sign the form in the designated area, where you will authorize the release of this information to the appropriate county department. You will also need to enter the date of the request.
- If you are completing the form on behalf of the mother and are not a parent, relative, or guardian, fill in Section C. This includes your details, such as your name, title, National Provider Identifier (NPI) number if applicable, and contact information, followed by your signature.
- Once all information is correctly filled in, finalize the form. You can save your changes, download the document, print it, or share it as needed.
Complete your documents online today for timely processing and assistance.
To fill up a referral form effectively, start by gathering all necessary information such as patient demographics and medical history. Take your time to accurately complete the Newborn Referral Form by carefully providing details in each section. Lastly, double-check your entries for any errors before submission to ensure a smooth referral process.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.