Mother’s Name. Soc. Sec. #..................................................................... License#.......................................................................................... Home/Postal Address............................................................................................................................................................. Home phone (.........).................................................................Cell phone (........)................................................................. Mother’s workplace & phone................................................................................................................................................. Father’s Name......................................................................................................................................................................... Soc. Sec. #................................................................... License #......................................................................................... Home/Postal Address............................................................................................................................................................. Home phone (..........)................................................................Cell phone (.........)................................................................ Father’s workplace & phone................................................................................................................................................... Does either parent have limited access to their child? ........................................................................................................... If so, legal documentation must be produced and on file. Legal Guardian, if other than above....................................................................................................................................... Home/Postal address………………………………………………………………………………………………………... Home phone (…......)..........................................................Cell phone (…….)……………………………………………. Workplace name & phone number…………………………………………………………………………………………. Should XXXX be unable to reach the parents/guardians in an emergency, who can we call?
Mother’s Name. In this field enter the first name, middle initial, and last name of the mother of the newborn infant. Address: In this field enter the address of the mother of the newborn infant – stxxxx xxxxxxx, xxxx, xxxxx, and zip code. Mother’s Medicaid ID Number: In this field enter the ten digit Medicaid or BadgerCare number of the mother of the newborn infant. The HMO staff person completing the report should fsign and date the form and send it to the address listed at the bottom of the report. The HMO does not have to use the above format. However, whatever format the HMO uses, the HMO must submit all of the information described above to the Department’s fiscal agent. MEDICAID AND BADGERCARE HMO NEWBORN REPORT Please print, type, or complete in a legible manner
Mother’s Name. Fathers’s Name: ...................................................
