Introduction To The Comprehensive Perinatal Services Program (Cpsp)

Introduction to the

Comprehensive Perinatal Services Program

(CPSP)

Date:

Member Information

Certificate Number

Member Name

Please check correct box:

I want to receive CPSP services

I do not want to receive CPSP services

CPSP

Please indicate below where services will be provided:

In office

Other provider (specify)

I have been informed about CPSP services which are available to me including Caring for

My Unborn Baby, Social Services, Healthy Eating, and Healthy Education. I have been given a

pamphlet that explains the program.

Member’s Signature:

This form MUST be signed and filed in the member’s chart.

Blue Cross of California is an Independent Licensee of the Blue Cross Association.

® is a registered mark and SM is a service mark of the Blue Cross Association.

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Parent category: Education