CDP Billing Cover Sheet * = required to billClient code:(Required) Doula name:(Required) Has doula contact info changed (address, phone number, email, or other)? No Yes (If yes, update Vishnu) Packet documentsRequired Documents Checklist Completed Confidentiality Release Form signed(Required) Completed Date signed:(Required) MM slash DD slash YYYY Letter of Agreement Completed CDP Data Collection Form Completed Birth Reflection Summary (if doula attended birth) Completed Online Birth Data Survey Completed Adverse Childhood Experiences Scale (ACES) Completed Declined Edinburgh Postnatal Depression Scale Completed Declined Healthy Families Referral Completed Declined Media Release Completed Declined Transportation Waiver Completed Declined Invoice Completed Total charges: Client informationClient name:(Required) First Last Medicaid Provider(Required) IHN OHP Cawem List member ID:(Required) Client Date of Birth:(Required) MM slash DD slash YYYY Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Client Phone:Last Menstrual Period:(Required) MM slash DD slash YYYY Baby DOB:(Required) MM slash DD slash YYYY Private InsurancePrivate Insurance provider: Private insurance group number: Private insurance member ID: Is client insured through a spouse or other family member’s insurance policy? Yes No If, yes list insured person’s info:Insured person's name: First Last Insured person’s DOB: MM slash DD slash YYYY Insured person’s address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insured person’s insurance company: Insured person’s group number: Insured person’s member ID: BillingGlobal(Required) Vaginal delivery: 59400 Cesarean-delivery: 59510 VBAC: 59610 CBAC: 59618 Place of service = where baby is born(Required) 21- Hospital 25- Birth center 12- Home 02- Telehealth Hospital facility name: Birth center facility name: Address if different than above Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Specify if Zoom, phone, Google Meets etc.: Itemized- (each billable item must include a date and place of service)(Required) Vaginal delivery- 59409 Cesarean-delivery- 59514 VBAC- 59612 CBAC- 59620 Client visit- 59899 (hospital, home, telehealth) Date of service for 59409: MM slash DD slash YYYY Place of service for 59409: Date of service for 59514: MM slash DD slash YYYY Place of service for 59514: Date of service for 59612: MM slash DD slash YYYY Place of service for 59612: Date of service for 59620: MM slash DD slash YYYY Place of service for 59620: Date of service for 59899: MM slash DD slash YYYY Place of service for 59899:
