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Please complete the intake form below:

Mom's Information

First Name *

Last Name *

Email *

Phone *

Mom's Date of Birth *

Street Address *

City *

State *

Postal code *

Baby's Information

Baby's First and Last Name: *

Baby's Gender *

Select option

Female
Male
Baby not born yet
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Baby's Date of Birth *

(enter today's date for prenatal)

Insurance Information

Insurance Carrier *

Anthem PPO

Aetna

BCBS PPO

Cigna

UHC

Medicaid

Other Insurance

Uninsured

BCBS & Anthem Clients: Please double check that your plan is PPO, it will have the letters “PPO” in the suitcase on the front of your card.

Do you have one of the following plans? •FEP •EPO •Highmark of WV/DE/PA •BCBS of TX •BCBS of MI •BCBS of FL •PEBA/MUSC •BCBS of LA •Regence •Wellmark

Yes

No

Is your UHC plan one of the following plans? -Community Plan -Doctors Plan -Core Plus -Charter EPO

Yes

No

Do you have Aetna Better Health (Medicaid)?

Yes

No

Insurance Plan Name *

ie: Horizon BCBS, UMR, GEHA etc.

Policy Holder *

Self
Spouse
Other
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Policy Holder Name

Policy Holder DOB

Mom's Member Number *

Mom's Group Policy Number *

Mom's Insurance Card (Front) *

Mom's Insurance Card (Back) *

For postnatal lactation appointments, both mother and baby are considered patients. Each visit includes evaluating feeding, weight, oral function, and other factors for both of you, so insurance requires us to bill for both you and your baby.

Is baby on the same insurance plan? *

Yes (select if baby is not born yet)
No
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Baby's Policy Holder Name *

Mom's name, Dad's name, etc.

Policy Holder's Relationship to Baby *

Select option

Parent
Other
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Baby's Policy Holder DOB

Child's Insurance Carrier

Anthem PPO

Aetna

BCBS PPO

Cigna

UHC

Other Insurance

Baby's Insurance Group Policy Number

Baby's Insurance Member Number

Baby's Insurance Card (Front)

Baby's Insurance Card (Back)

Type of Visit Requested *

Prenatal Consultation
Postpartum Consultation
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