Amerigroup Breastfeeding Class Registration Form / Pre-Lactation

Amerigroup Breastfeeding Class Registration Form
Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail Address
example@example.com
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
What county do you reside in?
Race

Black/African-AmericanBlack/AfricanBlack/Caribbean/West IndianMiddle Eastern/North AfricanLatine/Latina/LatinxSoutheast AsianEast AsianSouth AsianWhiteAmerican Indian or Alaska NativecMixed Race/MultiracialOther
Age
Date of Birth

MonthDayYear
Do you identify as part of the LGBTQIA+ community?
What is your gender identity?
Estimated Due Date

MonthDayYear
Date
What is the highest degree or level of school you have completed?
What is your marital status?
Are you a member of Amerigroup?
If you do not have Amerigroup, who is your insurance provider?

Medicaid: CareSourceMedicaid: Peach StateMedicaid: WellcareMedicaidOther- PrivateN/A- I do not currently have health insuranceN/A- I am an Amerigroup member
Are you in need of referrals from your Case Manager? If so, please specify.
Will your partner be attending the classes?

YesNoI am unsure
Type a question
Photo Release Form
Amerigroup Community Care Photo Release Form: This form says that you agree to allow Amerigroup the right to use any images and sounds (visuals and audios) in any format from the event today. If you agree, please read the following and sign below. 1. You agree to give Amerigroup all rights to use and copy any images and sounds of you and your family. These may be used for any purpose. 2. You will not blame or sue Amerigroup for any harm, damages or losses. It does not matter how they happen or who does them. 3.You will not let anyone else sue Amerigroup for you or in your name. This release shall be governed by the laws of the state of Georgia.

Yes, I agreeNo, I do not agree
Agreed by:

Signature
Print Name
Today's Date

MonthDayYear
Date
Member Testimonial Consent and Authorization to Release Form
This form states: I agree to share my story about my experience with and for Anthem, Inc. and its designees, including any of its affiliated or subsidiary companies (“Anthem”). My story may be shared to help describe how Anthem’s products, services or programs work or benefit members like me or for any Anthem advertising or business purposes deemed appropriate by Anthem. What may be used and disclosed in telling my story: 1. My name and my company name, if applicable. 2. The details of my personal experience with Anthem. 3. Photographs, Film or Videotape taken by Anthem of me or provided by me to Anthem. 4. Other information that Anthem deems necessary to tell my story completely and effectively. How and to whom my story might be told: 1. With printed or electronic materials, publications, presentations, online, web or other multimedia venues. 2. To Anthem customers, employees, associates, sales people, prospective customers, or the general public. Other things I agree to and acknowledge: 1. The information in my story is accurate and a reflection of my true experience. 2. This release is voluntary. 3. Any photographs, film, or videotape of me is the property of Anthem, solely and completely. I hereby exclusively assign to Anthem all rights, title and interest there to, including any and all results and proceeds from said use or appearance. 4. Anthem is not obliged to make any use of my interview or exercise any of the rights granted Anthem by this Release. 5. I will not get paid for sharing my story. I also release Anthem from any obligation to make any payment to me for sharing my information, or from any liability incurred in connection with the use of this material. 6. Anthem will not condition my enrollment or eligibility for benefits, treatment, or payment because I agreed to sign this form. I am entitled to a copy of this authorization to release. I have read, understand, and agree to this Testimonial Consent and Authorization to Release and consent to and authorize the use and disclosure of my information as described on this form.

Yes, I agreeNo, I do not agree
Signature ("Releaser"):
Print Name
Today's Date

MonthDayYear
Date
If Minor Child Present: I hereby represent that I am the legal guardian of (name of child) blanks, who is under the age of 18. I have read, understand, and agree to this Testimonial Consent and Authorization to Release, and I have the right to sign this Testimonial Consent and Authorization to Release on behalf of the named child.
Designated Legal Representative / Guardian: If this form is signed by a legal representative or guardian on behalf of a member, please complete the information below and attach a copy of a a court order or other documentation (such as a Power of Attorney)establishing custody, or other legal documentation demonstrating the authority of the legal representative to act on the member’s behalf. Legal Representative (Print full name):
Legal relationship to the member:
Signature
Date

MonthDayYear
Date

- Are you currently pregnant or postpartum?
- Date of Delivery
  
  MonthDayYear
  Date
- Number of Previous Children
- Number of Previous Breastfed Children
- Previous Breast Surgeries
- Are you currently taking medications
- After completing the series, do you plan to breastfeed?
- Are you currently breastfeeding?
- Is breastfeeding going well for you and your baby? (If they are breastfeeding)
- If no: How is breastfeeding going for mom and infant (Check all that apply):
  
  Difficulty LatchingLow milk supplyMedicationMother/baby seperationPain associated with breastfeedingOther
- Do you plan to return to work/school?
- Will you have a supportive employer?
- Accessible place to safely store milk?
- Access to private place to pump?
- Access to clean breast pump?
- Will you require resources from your case manager?
- Should be Empty:

Amerigroup Breastfeeding Class Registration Form

Photo Release Form

Member Testimonial Consent and Authorization to Release Form