Form Mc 330 - Newborn Referral
Download a blank fillable Form Mc 330 - Newborn Referral in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Mc 330 - Newborn Referral with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Department of Health Care Services
State of California—Health and Human Services Agency
NEWBORN REFERRAL
(P
.)
LEASE USE INK AND PRESS FIRMLY
The Newborn Referral Form is used to assist a Medi-Cal eligible mom to report the birth of her child(ren) to Medi-Cal.
By completing the information on this form, you help the county confirm the eligibility of the newborn so that the newborn
can begin receiving Medi-Cal services. Mail or fax this fo rm to the county. County information is located on the back of
this form. Any changes to the household must be reported to t he county, so, turn in this information quickly. The mother
may also report the birth by phone to her eligibility worker. If you are a cting on behalf of the mother, and are not a spouse,
relative, or guardian, then your signature and identifying inform ation is required in Section C. If entering through the
Gateway Program, enter the Benefits Identification Card (BIC) number assigned to the infant (optional).
SECTION A The mother’s Medi-Cal card can be used during the birth month and the month following for services and billing
for the newborn.
Mother’s name (first, MI, last)
Mother’s date of birth
BIC or SSN
Mailing address (number and street) or location
County
City
State
ZIP code
Telephone number
(
)
SECTION B Reminder: A child born to a mother with restricted benefits is eligible for full-scope benefits.
Optional—BIC number
Newborn name (first, MI, last)
Date of birth (month/day/year)
Gender
Male
Female
Optional—BIC number
Newborn 2 name (first, MI, last)
Date of birth (month/day/year) Gender
Male
Female
Optional—BIC number
Newborn 3 name (first, MI, last)
Date of birth (month/day/year) Gender
Male
Female
Newborn 4 name (first, MI, last)
Date of birth (month/day/year) Gender
Optional—BIC number
Male
Female
Newborn 5 name (first, MI, last)
Date of birth (month/day/year) Gender
Optional—BIC number
Male
Female
Where born (hospital name, clinic name, etc.)
Address (number and street, if available)
State
ZIP code
City
I hereby authorize release of this information to the County Department of Social Services/county welfare department.
Date of request
Parent/Relative/Guardian (of the infant) signature
⌦
SECTION C (Fill in this section if form was completed by person other than parent, relative, or guardian.)
Completed by (PLEASE PRINT)
Title
National Provider Identifier (NPI) Number (If Medi-Cal provider/hospital/clinic/group, etc.) Telephone number
I certify to the best of my knowledge that the information above is verified and accurate.
Signature (person other than parent, relative, or guardian)
Date completed
⌦
For provider billing inquiries or concerns on how to bill for infants, call the EDS Billing Hotline at 1-800-541-5555.
Original—County
Copy 1 — Hospital/Clinic/Nurse-Midwife/CAA/AR
Copy 2 —Parent/Relative/Guardian
Distribution:
MC 330 (01/15)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal