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Enrollment Form 2009

Medicaid Maternity Program

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                                                                                                     Patient Information

                                                                                                   * - denotes fields that are REQUIRED
 * Last Name * First Name   Middle Initial    * EDC ex:013104
 * Address  * Phone # ex. 2055552243
 * City (don't abbreviate)  * State   * Zip   County  Other Phone#
Second Address
 * Social Security #ex:117238109      * Birth Date ex:040578     Age    
* Race              Marital Status
* Medicaid # or Application Date/Site   Eligibility Category
                                                                                                * County Code
Do you have other health insurance? (List even if it will not cover maternity) 
Does it cover maternity? 
Insurance Company            Policy #                      
Effective Date:                    Termination Date:        
Policyholder's Name           Relationship to Patient 
Policyholders Date of Birth:        Policyholder's Gender 
Group Name/Number       Insurance Co. Phone #

                                                                                                     Risk Assessment * - denotes fields that are REQUIRED

 
* Date of Last Pregnancy:    * Previous Fetal Loss:    * Pregnancy Planned:
* Psychological Risk at Enrollment:    * Medical Risk Status at Enrollment:
* Previous Preterm Births (less than 37 weeks):    * Previously enrolled in Plan?:
* Smoker or Recent Quitter (within last 2 months)?:     * Smoking cessation Form Completed:

                                                                                                     Provider Selection (Click on link to expand) * - denotes fields that are REQUIRED

After looking at the current list of providers, I choose the following:

Provider Name Telephone # If multiple locations, which locations
 * 1.
    2.

Appointment made?     Date of Appointment: ex:040578   

Time of Appointment:              
* Care Coordinator Name: Care Coord. Steps Ahead Provider#   
CC Phone:    * Enroll Site:      
If DCHP change, select one:

                                                                                                     AFFIRMATIONS

  1. I have been given a copy of the Member Handbook, which contains the Rights and Duties and the Agreement to Receive Prenatal Care.
  2. The Grievance and Provider Choice procedures have been explained to me.
  3. I have been given a list of Delivering Physicians and hospitals to choose from . I made my own choice. Initial________
  4. What to do in the case of a real emergency has also been explained to me.
  5. I understand that if I am not approved for Medicaid, I must make payment plans with all of my healthcare providers and the hospital.
  6. I give permission for the release of information for those purposes directly related to the administration of the Medicaid Maternity 
    Program. These purposes include, but are not limited to, establishing eligibility for medical services and quality management. I 
    understand that my Care coordinator shall disclose information about my health care providers for the above reasons.
  7. I have had a chance to ask questions, if I did not understand, and I agree to fully participate in the Medicaid Maternity Program.
  8. I agree to keep my Care Coordinator informed, and to keep all prenatal and Care Coordination appointments/encounters.

        

                                                                                  
Enrollee Signature Date Person Completing Enrollment Form

 

   **Use the Print function in the File menu to Print this form before submitting.**