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Hospital

FOR HOSPITAL USE ONLY

Hospitals should use the marked hospital version application for any pregnant inpatient who doesn't have coverage on or before their date of delivery. 

The Application must be signed and completed, in its entirety, and faxed to CoverKids at 1-866-913-1046.

English Application

Aplicacion en espanol

 

Use the CoverKids Birth Reporting form only for pregnant women enrolled in CoverKids.

English

Espanol