DMAS-213 Hospital COMMONWEALTH of VIRGINIA RVSD1213

Department of Medical Assistance Services MEDICAID/FAMIS NEWBORN ELIGIBILITY NOTIFICATION HOSPITAL USE ONLY

This document is the official notification of the child’s birth for Medicaid or FAMIS enrollment. For children born to a Medicaid/FAMIS/FAMIS MOMS eligible mother, the Medicaid/FAMIS eligibility for the newborn begins on the date of birth.

ALL QUESTIONS MUST BE ANSWERED IN ORDER TO BE PROCESSED (Please Type or Print Clearly) Mother’

s Name Last First M.I. Mother’ - - Mother’ / / s SSN MM/DD/YY s Date Mother’ Street

City State Zip Mother’ - - Mother’ ( ) - Full Name of Newbor Birth n(s) Date Sex Race / / Last First MI MM/DD/YY / / Last First MI MM/DD/YY / / Last First MI MM/DD/YY

Submitt Signatu

ed by Name and re Hospital Title Telepho Name ne # ( ) - Hospital Address **NEW** EXPEDITED ELECTRONIC REPORTING OF DEEMED DSS Use Only NEWBORNS: Hospital staff can access the “Newborn E-213” link via Date Received / / DMAS provider web portal and log in utilizing their user name and MM/DD/YY password: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal Within one (1) business day, the hospital staff will receive secure email with Date Processed / / the 12 digit enrollee ID and infant’s MCO name. MM/DD/YY

DMAS-213 Hospital COMMONWEALTH OF VIRGINIA RVSD1213 Note: Medicaid/FAMIS newborns must If using the manual process, please fax or mail form immediately to the local be linked to their mother’s case when enrolled in MMIS. DSS office for the mother’s case.

DMAS-213 Hospital COMMONWEALTH OF VIRGINIA RVSD1213