Doula Services Recommendation Form - Additional Postpartum visit(s) request
Additional support for postpartum follow-up care
To request doula services covered by CenCal Health, members need a recommendation from a licensed provider.
Recommendations can be submitted by filling out and submitting this form, by fax (805) 681-3071 or via secure link at
https://gateway.cencalhealth.org/form/hs
If all information entered is complete, this submitted recommendation form will approve a doula to render one initial prenatal visit;
eight visits during the prenatal period, including up to one year after pregnancy; nine (9) additional postpartum visits.
If you are a licensed provider - By providing this recommendation for doula services, you acknowledge that the CenCal Health member would benefit from non-clinical
doula services in addition to appropriate clinical care. A recommendation is not the same as a referral, prescription, or medical order.
If you are a doula provider – You must retain the record of a licensed provider’s recommendation for each member prior to the initiation of their doula care;
the record must be stored in a manner consistent with HIPAA requirements. Prior approval of this recommendation form is required prior to service;
once this form is submitted it can be referenced on the CenCal Health Provider Portal with a recommendation confirmation number.
Please add this recommendation number to all billed claims.