Request for Services
Who is this request for?
Myself or my child
A friend or family member
A patient or participant for whom I'd like to make a referral to Everyday Miracles (provider, patient support, WIC, community orgs.)
I'm an Everyday Miracles doula filling out a request for a client you are already plan to work with.
Referral Source Information
Please give us your information in case we need to contact you about this request. After this section, you will fill out the rest of the request form as if you were the client.
Is this referral part of a special partnership program?
Upendo Program
Allina Birth Equity Project
Northside Achievement Zone (NAZ)
No special program
First & Last Name
Organization
Role
Phone
Email
Insurance Information
Lead Source
Currently Pregnant
Please select...
Yes
No
Yes, You are currently pregnant or No, you are not currently pregnant and requesting a breast pump OR car seat OR both.
Insurance Type
Please select...
State-Sponsored Blue Plus
State-Sponsored Health Partners
Private/Commercial Health Partners (breast pumps only)
State-Sponsored South Country Health Alliance
State-Sponsored UCare
Hennepin Health
Straight MA
State-Sponsored United Healthcare
Private/Commercial UCare (car seats & breast pumps only)
PrimeWest
Private/Commercial Blue Cross Blue Shield (breast pumps only)
Medica
If you do not select the CORRECT insurance type, you will not be able to request all the services you are eligible for.
PMI/MHCP Number
Where to find this info on your card
8 digit number (
please include all 8 digits, even if some of them are zeros
)
Insurance ID Number
Information About the Person Who Will Receive Services (Parent if requesting a car seat.)
First Name
Middle Initial
Last Name
Pronouns
she/her
he/him
they/them
other
Birthdate
This is
YOUR date of birth
, not your child's due date or birthdate.
Were you born outside the United States?
Yes
No
Previous Everyday Miracles Client
Please select...
Yes
No
Phone
Leave Detail Voice Message
Please select...
Yes
No
Email
Street
City
County
Please select...
Hennepin
Ramsey
Dakota
Anoka
Washington
St. Louis
Stearns
Olmsted
Scott
Wright
Carver
Sherburne
Blue Earth
Other county
State/Province
Zip/Postal Code
Estimated Due Date
This is the date you expect to have your baby, not your own date of birth.
Ethnicity
Please select...
Afghan
African American
African Descent
Asian/Pacific Islander
Caucasian
Hispanic/Latina
Hmong
Native American
Somali
Other/Mixed
Prefer not to answer
Primary Language
Speak English
Please select...
Yes
No
PLEASE SELECT THE SERVICES YOU ARE REQUESTING BELOW
Car Seat Request
YES, I would like to request a car seat(s)!
Eligible for a car seat
Car Seat for Current Pregnancy
Please select...
Yes
No
Please check this box if you are expecting multiples (twins, triplets, etc.)
Yes, I am currently pregnant with multiples.
Do you have a child (8 years or younger) who you'd like to request a car seat for?
Please select...
Yes
No
Additional Child 1
Child's First Name
Child's Middle Initial
Child's Last Name
Child's Birthdate
Child's Estimated Weight
Please enter approximate weight in whole pounds. For example: 25
Child's Insurance Type
Please select...
State-Sponsored Blue Plus
State-Sponsored Health Partners
State-Sponsored UCare
Private/Commercial UCare
Hennepin Health
Child's PMI/MHCP Number
Child's Insurance ID
I want to add a second child
Additional Child 2
Child's First Name
Child's Middle Initial
Child's Last Name
Child's Birthdate
Child's Estimated Weight
Please enter approximate weight in whole pounds. For example: 25
Child's Insurance Type
Please select...
State-Sponsored Blue Plus
State-Sponsored Health Partners
State-Sponsored UCare
Private/Commercial UCare
Child's PMI/MHCP Number
Child's Insurance ID
I want to add a third child
Additional Child 3
Child's First Name
Child's Middle Initial
Child's Last Name
Child's Birthdate
Child's Estimated Weight
Please enter approximate weight in whole pounds. For example: 25
Child's Insurance Type
Please select...
State-Sponsored Blue Plus
State-Sponsored Health Partners
State-Sponsored UCare
Private/Commercial UCare
Child's PMI/MHCP Number
Child's Insurance ID
I want to add a fourth child
Additional Child 4
Child's First Name
Child's Middle Initial
Child's Last Name
Child's Birthdate
Child's Estimated Weight
Please enter approximate weight in whole pounds. For example: 25
Child's Insurance Type
Please select...
State-Sponsored Blue Plus
State-Sponsored Health Partners
State-Sponsored UCare
Private/Commercial UCare
Child's PMI/MHCP Number
Child's Insurance ID
I want to add a fifth child
Additional Child 5
Child's First Name
Child's Middle Initial
Child's Last Name
Child's Birthdate
Child's Estimated Weight
Please enter approximate weight in whole pounds. For example: 25
Child's Insurance Type
Please select...
State-Sponsored Blue Plus
State-Sponsored Health Partners
State-Sponsored UCare
Private/Commercial UCare
Child's PMI/MHCP Number
Child's Insurance ID
I want to add a sixth child
Additional Child 6
Child's First Name
Child's Last Name
Child's Birthdate
Child's Estimated Weight
Please enter approximate weight in whole pounds. For example: 25
Child's Insurance Type
Please select...
State-Sponsored Blue Plus
State-Sponsored Health Partners
State-Sponsored UCare
Private/Commercial UCare
Child's PMI/MHCP Number
Child's Insurance ID
If you would like to request a car seat for additional children, please email
abby@everyday-miracles.org
Breast Pump Request
YES, I would like to request a breast pump!
Eligible for a breast pump
We offer a few different pumps. Some are covered 100% by insurance and some models require an out-of-pocket upgrade charge. If you select a model that requires an upgrade charge, we will collect that payment below.
Breast Pump Choice
Please select...
Medela Pump-in-Style
Spectra S1 ($50 upcharge)
Spectra S2
Other Medela and Spectra Upgrade
Spectra S9
We will need a prescription from your healthcare provider for a breast pump. You can email
abby@everyday-miracles.org
or fax (612-353-6437) this prescription to us.
If you already have the prescription, you can upload a photo of it here.
Please
click here
to make your payment for your breast pump upgrade.
Breast Pump Request
YES, I would like to request a breast pump!
Insurance Type
Please select...
State Sponsored Blue Plus
Private Blue Cross
State Sponsored Health Partners
Private Health Partners
State Sponsored Hennepin Health
State Sponsored UCARE
Private UCARE
Insurance ID Number
Eligible for a breast pump
We offer a few different pumps. Some are covered 100% by insurance and some models require an out-of-pocket upgrade charge. If you select a model that requires an upgrade charge, we will collect that payment below.
Breast Pump Choice
Please select...
Medela Pump-in-Style
Spectra S1 ($50 upcharge)
Spectra S2
Other Medela and Spectra Upgrade
We will need a prescription from your healthcare provider for a breast pump. You can email
abby@everyday-miracles.org
or fax (612-353-6437) this prescription to us.
If you already have the prescription, you can upload a photo of it here.
Please
click here
to make your payment for your breast pump upgrade.
Doula Request
YES, I would you like to request a doula!
Eligible for a doula
If you are ALREADY working with a specific Everyday Miracles doula
AND
THAT DOULA HAS AGREED TO WORK WITH YOU, please enter your doula's name.
Name only. 30 character limit
Birth Location
Please select...
A New Story Birth Center
Abbott Northwestern (Mother Baby Center)
Buffalo Hospital
Centracare (St. Cloud)
Essentia (Duluth)
Fairview Range Medical Center
Fairview Ridges (Burnsville)
Fairview Riverside (U of M)
Fairview Southdale (Edina)
HCMC (Minneapolis)
Health Foundations Birth Center
Home Birth
Hudson Hospital
Lakeview Hospital (Stillwater)
Mankato Hospital
Maple Grove Hospital
Mayo
Mercy Hospital (Mother Baby Center)
Methodist (St. Louis Park)
Minnesota Birth Center-MPLS
Minnesota Birth Center-St. Paul
Monticello Hospital
North Memorial (Robbinsdale)
Northfield
Olmsted Medical Center
Owatonna Hospital
Regions (St. Paul)
Ridgeview Medical Center (Waconia)
River Valley Birth Center
Roots Community Birth Center
St. Cloud Hospital
St. Francis (Shakopee)
St. Johns (Maplewood)
St. Luke's (Duluth)
St. Mary's Essentia Health
United (Mother Baby Center)
Willow Birth Center
Woodwinds (Woodbury)
Other
Undecided
Fairview Northland Medical Center
Other Birth Location
Clinic
Healthcare Provider
The name of your midwife or doctor.
I would like to request a doula who is vaccinated for COVID-19.
Yes
No
It Doesn't Matter
Comments
Class Attendance
Clients requesting a doula are expected to take childbirth education classes at Everyday Miracles if at all possible. Classes are currently all being held virtually via Zoom.
Do you plan to take classes at Everyday Miracles?
Please select...
I have already attended classes at Everyday Miracles during this pregnancy
I am looking forward to attending virtual classes
I am not sure I will attend virtual classes
I am not going to attend virtual classes
Unable to Attend Classes
Please tell us why you do not plan to take part in classes through Everyday Miracles.
Please select...
I don't have access to a smartphone or computer
I don't have childcare
Language barrier
I just don't want to
Classes
Everyday Miracles offers classes about childbirth, lactation, and newborn care. Most of these classes are fully covered by your insurance with no out-of-pocket cost to you. Are you interested in taking classes at Everyday Miracles?
Are you interested in taking classes at Everyday Miracles?
YES, I would like to take classes covered by my insurance!
Eligible for core classes
If you are unable to select a service & all your insurance and county information is correct, you do not qualify for that service with Everyday Miracles.
Everyday Miracles
Request for Services
Request for Services