Urban Baby Beginnings Community Cares

Locality *

Who can be referred?

Any prenatal individual/family located in the Tri-Cities and Greater Richmond area can participate.

Due dates less that 7 weeks away and you need a Doula? Please contact our office to discuss your options.

Who will benefit most?

Any birthing individual will benefit from our services
Clients looking for Doula support
Expecting people who are at risk for preterm birth
Families who need Breastfeeding help
Those looking to expand their birth knowledge through classes and in-home visitation
People who have limited financial resources
Birthing persons who are high risk due to health-related or psychosocial factors

What is the cost?

Cost is dependent on the services provided.

We currently accept certain Medicaid plans. Members of these plans may be covered 100%; plan restrictions apply.

Payment plans available including a sliding scale for those who need it and do not qualify for approval under a qualified insurance plan.

Super Bill provided for HSA reimbursement.

Who can refer?

Anyone!

When will I hear back?

Please allow 48 business hours for a Pregnancy Navigator to contact you via email. If the request is urgent, please contact our office at 833-RVA-BABY between the hours of 10 am-2 pm M-Fri.

Referral Contact Name (Type N/A if not applicable)

Referral Contact Email

example@example.com

Referral Contact Phone

Area Code Phone Number

How can we help you? *

Village Birth Collective Doula Support Home Visiting Case Management Prenatal/Postpartum Classes Lactation Support (In-Home/Clinic) Maternal Depression Screening Support Group Baby Box

Client Information

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

Secondary Number

Area Code Phone Number

E-mail Address *

Confirmation Email

Insurance-Health Care Organization *

Private Insurance Tricare VA Medicaid/FAMIS Optima Family Care/FAMIS Optima Health Community Care Medicaid HMO Anthem HealthKeepers Plus Aetna Better Health Virginia Premier Uninsured/Self Pay

Date of Birth *

Date

Member ID# *

Service Authorization #

Ethnicity

African American Hispanic Caucasian Asian Native American Other

Select which applies *

6-13 weeks pregnant 14-20 weeks pregnant 21-32 weeks pregnant 33-40+ weeks pregnant Postpartum

Estimated Due Date/Date of Delivery *

Month Day Year

Additional Comments

Attach orders, face to face, health history, and demographics here

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