REFERRAL FORM

Use this form if you are a referring agency requesting services for your patient/client.
 

  • We receive a high volume of requests. Taking the time to read the information on the request form fully to make sure the client is eligible for the services being requested and including the most accurate information is the easiest way to ensure we can process requests as quickly as possible. If you have any questions, we ask that you contact us BEFORE submitting the request form. 
     
  • For most requests, we must communicate with the client before moving forward in the process. Please advise the client that you are making a request on their behalf, and to watch for and respond to additional communication from Everyday Miracles.
     
  • Due to the volume of requests, we do not automatically send a request confirmation to the referring organization. However, if you would like to follow up on a request, please contact us via email.
     
  • Note: the name listed on this request must exactly match  the name listed on the client's insurance card/plan, or we will be unable to validate coverage. We are not able to process requests without valid insurance information.

* = Required field

Request *
Please make sure you have reviewed accepted insurance types for each type of request on the previous page. Make your request ONLY if the client has that type of insurance. Doula availability for those 32 weeks and beyond is very limited and can only be made with prior approval from the doula coordinator: doulas@everyday-miracles.org
Program Eligibility *
I understand that Everyday Miracles can ONLY process requests for clients with a current/active Medicaid plan.
Car Seat Requests *
If you are requesting for a child (who is already born), we MUST HAVE the birthing parent's name and DOB in order to process the request. You may enter this information in the comments section of this form.
Car Seat Child *
If requesting a car seat for a child (who is ALREADY BORN) please make sure you fill out the form below for the child, not the parent. If you need seats for MULTIPLE CHILDREN, complete the form for the first child, then include the additional children in the ADDITIONAL COMMENTS section and include the following for each child: first and last name, child's DOB and child's insurance number.
Doula Requests *
YOU MUST contact the doula coordinator if you are requesting a doula and the client is 32 weeks pregnant or beyond. This should be done prior to submission, or the request WILL NOT BE PROCESSED. Please contact doulas@everyday-miracles.org
Client's Name *
Client's Name
If the child is already born, list the CHILD as the client. If this is for a birthing/expectant parent who has not yet given birth, please list the ADULT as the client.
Date of Birth *
Date of Birth
We need this information to verify program eligibility. If you are an expectant/birthing parent requesting a seat for your unborn child, please enter your DOB. If you are requesting a car seat for a child, please enter the child's DOB.
Estimated Due Date *
Estimated Due Date
Estimated date you expect your baby to be born. This information is required if the referral is for an expectant parent. If this request is not for an pregnant person, please enter the child's DOB.
Mobile Number *
Mobile Number
Address *
Address
What is this? This is an eight-digit number, which helps facilitate a swifter verification of Medicaid coverage. It can be found on a client's Minnesota Health Care Plan (MHCP) card
Insurance Type *
Please enter a valid insurance number, your referral will NOT be processed without one.
This is for car seat requests/referrals.
This information is required for all doula referrals.
Where are you being treated? Who are you seeing?
Race *
The following is based on the CDC categories of race. We use it to evaluate our program in relation to birth outcomes and disparities.
We use this information to try to offer culturally congruent support, if desired and when available. If you would like us to know more about the client's ethnic or cultural identity, please include it here.
Does the client speak English? *
Please note. We work hard and are honored to serve every client. However, we have limited staff and resources. If the client does not speak English, additional time may be needed to process the request. Please also be sure to include your direct contact information in the event we need additional assistance facilitating this request.
Your Information
Referral source contact information.
Referrer's Name *
Referrer's Name
Phone Number *
Phone Number
Client Communication *
We typically need additional information/confirmation from clients to complete any requests. Please advise the client you are making the request on their behalf. They should expect additional communication from Everyday Miracles and to respond promptly.

DOULAS

We do our very best to fulfill every request. However, please contact our Doula Coordinator BEFORE submitting your request if it is for someone who is 32 weeks pregnant or beyond. Doula availability is very limited in those cases.

CARSEATS

We work hard to get car seats to clients as soon as possible. Because of the high volume of requests, car seat deliveries may take up to three weeks after initial referral and deliveries are scheduled according to estimated due date. 

BREAST PUMPS

If you are requesting a breast pump, please request a prescription from your provider.  You can request that your provider fax the prescription to us at to our office at 612-353-6437 or give the prescription to us upon delivery of your breast pump. Breast pumps can be delivered or picked up.

QUESTIONS?

If you have any questions about doula request/referral, please contact Melissa Gutierrez Nelson. If you have questions about your car seat request, contact  Abby Peters.  If you have questions about breast pump requests, please email Debby Prudhomme.