Hospital Report Of Newborns printable pdf download

DEPARTMENT OF HEALTH AND MENTAL HYGIENE

MARYLAND MEDICAL ASSISTANCE PROGRAM

HOSPITAL REPORT OF NEWBORNS

DHMH USE ONLY

FAX FORM IMMEDIATELY TO:

MAIL FORM TO:

Date Received: _______________

Division of Recipient Eligibility

Date Processed: ______________

410-333-7012

201 West Preston Street

Processed By: _______________

Room SS7C

Baltimore, Maryland 21201

Mother’s Name: ___________________________________________________________________ DOB: ___/___/___

(Last)

(First)

(M.I.)

Mother’s Medical Assistance Number:

___/___/___/___/___/___/___/___/___/___/___/

Address: ____________________________________________________ S.S.#: ___ ___ ___ / ___ ___ / ___ ___ ___ ___

City: ___________________________________ State: _____________ Zip Code: ____________________

Full Name of Newborn (s)

Date of Birth

Sex

Birth Weight

Last

First

Month/ Day/ Year

M or F

Race

(A)

grams

(B)

grams

DHMH Use Only: MA Number Assigned:

(A) ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

(B) ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Name of Mother’s MCO: ___________________________________________

Complete Name of Hospital: __________________________________________________________________________________

Address: _________________________________________________________________

Telephone #:_____________________

_____________________________________________

____________________________________

________________

Printed Name of Person Completing Form

Signature of Person Completing Form

Date of Completion

Optional



Has parent selected pediatrician for ongoing care after discharge?

Yes

Name: __________________________________________________ Practice Name: __________________________________

Address: _________________________________________________________________________________________________

___________________________________________________________________________________________________

Note:

Automatic eligibility for the newborn(s) is dependent on the mother being eligible for and receiving Medical Assistance at

the time of the child’s or children’s birth and the child living with the mother. It is advisable to confirm the mother’s

eligibility status on the date of delivery by using the Eligibility Verification System (EVS). Do not submit this form if the

child will not be discharged to the mother.

DHMH 1184 (Rev. 8/08)

Hospital Report Of Newborns

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