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Community Doula Program
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Community Doula Program
  • Doulas
    • Want to be a Doula?
    • CDP Doula Private Page
  • Careproviders
  • Families
  • About Us
    • Meet the Doulas
  • Media
  • Contact Us
  • Donate

CDP Billing Cover Sheet

* = required to bill
Has doula contact info changed (address, phone number, email, or other)?

Packet documents

Required Documents Checklist
Confidentiality Release Form signed(Required)
MM slash DD slash YYYY
Letter of Agreement
CDP Data Collection Form
Birth Reflection Summary (if doula attended birth)
Online Birth Data Survey
Adverse Childhood Experiences Scale (ACES)
Edinburgh Postnatal Depression Scale
Healthy Families Referral
Media Release
Transportation Waiver
Invoice

Client information

Client name:(Required)
Medicaid Provider(Required)
MM slash DD slash YYYY
Client Address(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY

Private Insurance

Is client insured through a spouse or other family member’s insurance policy?
If, yes list insured person’s info:
Insured person's name:
MM slash DD slash YYYY
Insured person’s address

Billing

Global(Required)
Place of service = where baby is born(Required)
Address if different than above
Itemized- (each billable item must include a date and place of service)(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

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