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Newborn Form

Department of Medical Assistance Services MEDICAID/FAMIS NEWBORN

Reminder:If a submitted E-213 requires correction, please call the Cover Virginia Call Center at 1-855-242-8282.Thank you.

Reporter Details

Reporter Entity*

If MCO, which MCO?

Submitter Details

Submitter's Full Name*

Submitter's Job Title*

Organization Name * (Excluding MCOs)

Submitter's Telephone Number

Submitter's E-mail Address

Mother Details

Mother's Last Name*

Mother's First Name*

Mother's Middle Name / Initial

Mother's SSN

Mother's Date of Birth*

Is Mother's Medicaid Enrollee ID known*

Mother's Medicaid Enrollee ID Number

Mother's Telephone Number

Mother's Address Details:

Mother's Street

Mother's Street Line 2

Mother's City

Mother's State

Mother's Zipcode

Is this a single/multiple birth? *

Total in Birth

Newborn(s) Details

Newborn

Newborn's Last Name*

Newborn's First Name*

Newborn's Middle Name / Initial

Newborn's Date of Birth*

Newborn's Date of Death, if applicable

Newborn's Sex*

Newborn's Race

Does Newborn live in mother's household?*

Newborn's Address, if different from Mother's

Newborn's Street

Newborn's Street Line2

Newborn's City

Newborn's State

Newborn's Zipcode

Add another Newborn details

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