Medicaid Intake Form - The Mothership

First Name

Last Name

Preferred to Be Called

Pronunciation

Your Birthday

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Are you currently…? (check all that apply)

EDD or Baby's Birth Date

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Cell Phone Number

Secondary Phone Number

Address

City

Zip Code

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Emergency Contact

Emergency Contact Phone

Emergency Contact Email

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What Your NY State Medicaid Benefit Card ID NUMBER? (xxxxxx xxxx xxxx xxx xx) This is the same card that is used for SNAP.

What is your managed care plan MEMBER ID? (for example, the card may be from Healthfirst, Fidelis, MetroPlus, EmblemHealth, UnitedHealthcare, etc.)

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Upload a clear photo of your NYS Medicaid Benefit Identification Card (also called your Medicaid benefit card or CBIC). This is the card issued by New York State that can also be used for SNAP

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Please upload your health plan card (for example, Healthfirst, Fidelis, MetroPlus, EmblemHealth, UnitedHealthcare, etc.). (if applicable)

Managed Healthcare Plan Expiration Date (if applicable)

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Are you currently involved in foster care in NYC?

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Which hospital or birthing center are you planning to give birth at?

How many pregnancies have you had? (Please include miscarriages, abortions, and stillbirths)

Please state your general health. Do you have any conditions (physical or psychological) or recent illnesses, surgeries, accidents, or trauma that we should be aware of?

Explain any complications that you have had with this pregnancy, any restrictions your provider has given you, and any medications (prescription or OTC) / natural supplements / vitamins you are currently taking.

What kind of support are you hoping to receive from your doula?

What are your top priorities for your birth? (select all that apply)

Your Current Living Arrangements (select all that apply)

Where are you currently getting prenatal care? (Care Provider Name and Address)

Who will be present at your birth? Please include names, pronouns, contact information, and relationship to you.

Are there any additional concerns you would like to share (for example, prior pregnancy-related issues, social service needs, mental health concerns, trauma triggers, religious or cultural considerations, etc.)?

Requesting a specific doula? Please enter their name here. Matching is based on doula availbility.

Submit

Medicaid Doula Enrollment Form

Please Fill Out Your Intake Form - Medicaid Eligible Clients

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Bellevue Hospital
BronxCare Hospital Center
Brookdale Hospital and Medical Center
Brooklyn Hospital Center
Elmhurst Hospital
Flushing Hospital
Harlem Hospital
Jacobi Medical Center
Jamaica Hospital Medical Center
Kings County Hospital Center
Lenox Hill Hospital
Lincoln Medical Center
Long Island Jewish Forest Hills
Long Island Jewish Medical Center (Katz)
Maimonides Medical Center
Metropolitan Hospital Center
Montefiore Medical Center - Wakefield
Montefiore Medical Center - Weiler / Einstein)
Mount Sinai Hospital (East)
Mount Sinai West
New York Downtown Hospital Center
NY Presbyterian - Allen Hospital
NY Presbyterian - Brooklyn Methodist Hospital
NY Presbyterian - Columbia (Sloan / Morgan Stanley)
NY Presbyterian - Koch Center (Alexander Cohen)
NY Presbyterian - Lower Manhattan Hospital
NY Presbyterian - Queens
NY Presbyterian - Weill Cornell
North Central Bronx Hospital
NYU Langone - Brooklyn / Lutheran Medical Center
NYU Langone - Tisch
NYU Langone - Other
Queens Hospital Center
Richmond University Medical Center
South Brooklyn Health (previously Coney Island Hospital(
St Barnabas Hospital
St John's Episcopal Hospital
Staten Island University Hospital
SUNY Downstate Medical Center / University Hospital of Brooklyn
Woodhull Hospital
Wyckoff Heights Medical Center