State of idaho department of health and welfare optional reerral form for newborn medicaid coverage 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Part 1, which is to be completed by the Medicaid provider. Enter the provider's name and address, ensuring all fields are accurately filled.
3. In the Identifying Information section, provide the mother's name, address, Social Security Number, and Medicaid Identification Number if known. You can substitute a copy of the Medicaid I.D. card for some of this information.
4. Next, fill in the infant's name, date of birth, and sex. Indicate whether an application for a Social Security Number has been completed for the child.
5. Complete the father's information including name, address, Social Security Number, and date of birth.
6. Finally, ensure that the provider or representative signs at the bottom of Part 1 before submitting it.
7. After submission, Part 2 will be completed by the Department of Health and Welfare. Make sure to keep track of any correspondence regarding your infant's Medicaid identification number and eligibility effective date.

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