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Medicaid and Medi-Cal Doula Benefits Inquiry Form
All information shared will be kept private and secure in HIPAA compliant software. If you have questions, please email birthworkersofcolor@gmail.com
Legal Name (Must match insurance card)
*
First Name
Last Name
Nickname or Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Preferred Contact Method (Select all that apply)
Phone
Email
Text
Date of your Last Menstrual Period
*
-
Month
-
Day
Year
Date
Expected Delivery Date
*
-
Year
-
Month
Day
Date
What race/ethnicity best describes you?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Latino or Hispanic
White
I prefer not to answer
Arab/Middle Eastern
Other
Emergency Contact Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Doula Preferences
Doula support is based on availability so we will do our very best to match you with a doula that meets your unique needs. All of BWOCC doulas are trained in reproductive justice framework and provide care through a trauma-informed, culturally competent lens.
If you have already connected with a doula, please enter their name here.
Do you need doula support in a language other than English?
Yes
No
Other
Please share what you are looking for in a Doula so we can match you with best fit? (speaks a specific language, cultural, spiritual, or religions needs, experience supporting people with disabilities, LGBTQIA+ friendly, etc)
Is there anything else you would like to share with us? Are there any things you'd like us to know about your needs?
Insurance Information
Type of Services
Primary Insurance Provider (Ex: CA Medi-Cal/State Medicaid Card)
*
Primary Insurance ID Number
*
Upload Front and Back Copy of Your Primary Card
*
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Choose a file
Cancel
of
Do you have secondary insurance? (If yes, please upload all your insurance cards below)
Yes
No
Secondary Insurance Provider (Ex: Kaiser, Healthnet, Employer insurance, etc)
*
Secondary Insurance ID Number
*
Upload Front and Back Copy of Your Secondary Plan Card, front and back.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Permission to Share Information
By submitting this form you agree to share your protected health information with Birthworkers of Color Collective and the secure, HIPAA-compliant software programs we use to manage your care.
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