ORGANIZATION REFERRAL

 

Use this form if you are a referring agency requesting services for your patient/client. The name on the request must exactly match  the name listed on the client's insurance card/plan, or we will be unable to validate coverage. Please fill out as much of this form as possible, so we can process your request as quickly as possible. 

* = Required field


I would like to request: *
Please note the accepted insurance types listed below for each type of request. Make your request ONLY if you have that type of insurance. We are no longer doula requests for those birthing in 2016. Doula availability for those 32 weeks and beyond is very limited.
Request Program Eligibility *
I understand that Everyday Miracles has specific eligibility requirements for different types of requests/referrals. I understand that my request referral cannot be processed without valid insurance information.
Client's Name *
Client's Name
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 mother.
Phone Number *
Phone Number
Address *
Address
Insurance Type *
Please enter a valid insurance number, your referral will NOT be processed without one.
Date of Birth *
Date of Birth
We need this information to verify program eligibility. If you are an expectant mom 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.
This is for Car Seat requests/referrals for children only.
This information is required for all doula referrals.
Where are you being treated? Who are you seeing?
Does the client speak English? *
If you are making a doula request, please share any information that you feel would assist us in pairing you with a doula. You may include birth preferences, faith practices/traditions that may play a role in your birth, specific anxieties, personalities you feel most comfortable with or anything else you would like us to know when considering your doula match.
Your Information
Referral source contact information.
Referrer's Name *
Referrer's Name
Phone Number *
Phone Number

THINGS TO NOTE


Applicant MUST have a Medicaid plan, either straight MA or state-funded plans through HealthPartners, BluePlus or Medica. Applicants with private insurance are not eligible.


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.


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.


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  Shyla Earl.