Third Party Liability (Tpl) Notification Of Newborn Children Form printable pdf download

Department of Health & Hospitals

Third Party Liability (TPL) Notification of Newborn Children

In accordance with ACT No. 269 of the 2004 Regular Session of the Louisiana Legislature, this document will serve as

the required notification regarding the birth of the child named herein.

Date: _______________

Hospital Name: ________________________ Telephone No. : ___________ Contact Person: ____________

Was the newborn delivered in your facility? Yes _____ No _____

Facility Provider No.: _______________

Admission Date of Newborn Child: ____________________ Discharge Date: __________________________

Attending Provider Name: ____________________________________________________________________

Will the attending provider accept health insurance as Primary and Medicaid as Secondary? Yes __ No __

Was the newborn discharged to another facility? Yes _____ No ______

If yes, Facility Name: ________________________________________ Telephone No.: _______ ___________

MOTHER

FATHER

Name _______________________________________

Name ___________________________________________

Date of Birth ____________SSN __________________

Date of Birth _____________

SSN ___________________

Mailing Address _______________________________

Mailing Address ___________________________________

City ____________ State ___ Zip Code ____________

City _________________ State ____ Zip Code __________

Is the mother covered by Medicaid? Yes __ No __

Is the father covered under health insurance coverage?

Yes __________ No __________

Applied? Yes ____ No ____ Date applied __________

Name of Insurance Company _________________________

Will you enroll your newborn in your Employer Sponsored Insurance Plan?

Yes _____ No _____

Mother’s EMPLOYMENT

Father’s EMPLOYMENT

Employer ______________________________________

Employer ________________________________________

Telephone #: ___________________________________

Telephone #:______________________________________

NEW BORN

Name on Birth Certificate: First _____________________________ Middle _________________ Last ______________________________

Birth Date _________________Time of Birth ________________ Birth Weight _______________ Race ______ Sex ___________________

Single Birth _____ Multiple Births ______ NICU ______ Adopted __________

(In the event of multiple births, additional space is provided on the reverse side)

HEALTH INSURANCE

Is mother covered under any health insurance coverage? Yes ____ No ___ (If the parent(s) have more than one insurance plan,

please provide information related to the secondary plan on the reverse side)

PRIMARY PLAN: Name of Insurance Company: _____________________________ Group No.____________ Member No. ____________

Address: __________________________________ City: ________________ State: ___Zip Code: __________ Telephone _____________

Is the mother the employee, dependent spouse or individual policyholder: _____________________________________________________

Provide us with the address and name of person of the insurance company that this notification will be mailed to:

Company Name:___________________________________ Contact Name: _____________________________________

Address: ___________________________________ City __________________, State ___________ Zip Code __________

Email Address _______________________________ Fax Number ______________________________________________

cc: Department of Health & Hospitals, Third Party Liability – P. O. Box 91030, Baton Rouge, LA 70821-9030

Form TPLN 1-2005

Third Party Liability (Tpl) Notification Of Newborn Children Form

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