Doula Provider Services - Inbound Referrals Survey

Thank you for helping provide a continuum of support for those in need of doula support services. Please complete the form below as thoroughly as possible.

*An asterisk indicates a required field.

Press Submit when complete. You may also fax this form to +1 (858) 430-5551
Should you have any questions, you may call our office at 619-800-6443 or email us at info@happymama.global.

For more details about Happy Mama, visit https://happymama.global

REFERRED BY

Who is completing this form?(Required.)

Provider

Payer

Social Services / CBO

Happy Mama

Name of referring clinic/agency?(Required.)

Address 1

Address 2

City(Required.)

County

State(Required.)

Clinic/Agency Contact Name of Person Making the Referral(Required.)

Clinic/Agency Contact Phone Number(Required.)

Clinic/Agency Contact Email Address(Required.)

IS THIS A MEDI-CAL REFERRAL FROM A HEALTHCARE PROVIDER? (This is the provider recommendation section. Complete this section to fulfill Medi-Cal's recommendation requirement for doula services for Medi-Cal beneficiaries. All others select may no and skip to the next section, Client Details.)(Required.)

Yes

No

For Medi-Cal members, Doula services require a written recommendation submitted by a physician or other licensed practitioner of the healing arts acting within their scope of practice. The recommending provider does not have to be enrolled in Medi-Cal or a network provider. However, the following information is required:

I declare that the following information is true and correct:
1. I am a physician or other licensed practitioner of the healing arts.
2. I attest that the Medi-Cal member listed below would benefit from doula services and/or has requested doula services.

Yes, the above statements are true and correct.

Recommendations for Doula Services (Check all recommendations that apply)

First recommendation

Second recommendation (A second recommendation is required for up to nine additional visits within one year after the member’s pregnancy ends)

Recommending Provider's Information

Provider's First Name

Provider's Last Name

Provider's Title

Provider's NPI

Provider's Phone

Provider's Email

Provider's Fax Number

CLIENT DETAILS

Client's First Name(Required.)

Client's Last Name(Required.)

Client's Preferred Name

Preferred Pronoun(s)

She/her

He/his

They/Their

Other (please specify)

Date of Birth (MM/DD/YYYY)(Required.)

Client's Primary Phone Number (type N/A if not available or DK if unknown)(Required.)

Alternative Phone Number

Client's Email Address (type DK is unknown)(Required.)

Client's Street Address (type DK if unknown)

City

State

Zip Code

Number of Weeks Pregnant? (Or enter DK, If unknown)

Service Type Requested(Required.)

CLIENT INSURANCE INFORMATION

PRIMARY Insurance Information

Policy Number

Group Number

Subscriber Names

Subscriber Date of Birth

SECONDARY Insurance Information

Secondary Policy Number

Secondary Group Number

Secondary Subscriber Names

Secondary Subscriber Date of Birth

Preferred Language

Will an interpreter be needed at intake?

Yes

No

Does the client identify as part of any of these communities:(Required.)

Other (please specify)

PREGNANCY HISTORY

Name of Primary Care Physician

Provide the Primary Care Physician's Phone Number if Different from Referring Agency

Name of Obstetrician or Midwife

Provide the Obstetrician or Midwife's Phone Number if Different from Referring Agency

Name of hospital/birth center currently scheduled

Estimated Due Date? (MM/DD/YYYY)(Required.)

Any additional past or ongoing symptoms during this pregnancy? Summary of member issue(s), need(s), and concerns(s):

Additional Information