Provider Referral | Birthing Gently

MassHealth Provider Referral Form

Referring Provider Name

Referring Provider Email

Referring Provider Phone

Patient First + Last Name

EDD

Patient Email

Patient Phone

Language Spoken

If you are a MGB provider making a referral for a patient who is admitted on the L&D floor please fill out the form and text or call 978-314-5533 to let us know you are making a last minute urgent referral.

Confirm patient is currently on MassHealth

Confirmed

Not Currently

Patient's Name as it appears on MassHealth ID Card

MassHealth ID#

Special Concerns (physical, emotional, mental)

Providers - please notify your patient that Birthing Gently will send a text message to verify their interest in a MassHealth doula.

A response is required in order to move forward with their participation in the doula program.

Thank you - we have received your referral! We will reach out to your patient within 48 hours.