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Newborn form 2026
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- Click ‘Get Form’ to open the Newborn Referral Form in the editor.
- In Section A, enter the mother's full name, date of birth, and either her BIC or SSN. Provide the mailing address, city, county, state, ZIP code, and telephone number.
- Move to Section B to fill in details for each newborn. Enter their names, dates of birth, and gender. If applicable, include their optional BIC numbers.
- Indicate where the newborn was born by providing the hospital or clinic name and address if available.
- In Section C, if you are completing this form on behalf of someone else, provide your information including title and NPI number if applicable.
- Finally, review all entered information for accuracy before signing and dating the form at the bottom.
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mc330
Bond with a Newly Born, Adopted or Fostered Child (Forms PFL-1. The form package for bonding leave includes the following forms: Request for Paid Family Leave
To report a newborn to Health Choice Utah, fax in this completed form to (801) 587-4855. Each newborn requires a separate form Twin A: Male or Female Twin B: