Fillable NOTIFICATION OF NEWBORN - ct

Description
W-416 (Rev. 6/08) NOTIFICATION OF NEWBORN TO: THE DEPARTMENT OF SOCIAL SERVICES 1. Mother's Information - To be completed by hospital official. Name Address Date of Birth SSN Is this mother an active Medicaid recipient? Will the newborn be released to the mother? Yes Yes No No If Yes, DSS Client ID # 2. Hospital Certification To be completed and signed by hospital official. I certify that baby's name (first,...
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