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.

*FIELDS ARE MANDATORY


PATIENT INFORMATION:
LICENSED PROVIDER RECOMMENDATION REQUEST:
Recommending Licensed Provider Name and Specialty*:
DOULA PROVIDER RECOMMENDATION:
*Under the doula benefit, Medi-Cal defines a “licensed provider” as a physician or other licensed practitioner of the healing arts, including nurse midwives, nurse practitioners, licensed midwives, and behavioral health providers, acting within their scope of practice under state law. The recommending licensed provider does not need to be enrolled in Medi-Cal or be a network provider within the beneficiary’s managed care plan. Under Medi-Cal, a beneficiary who is pregnant within the past year, and would either benefit from doula services or who requests doula services, would meet the medical necessity criteria for a recommendation for doula services. For mor information, visit www.dhcs.ca.gov.