ACADIAN MEDICAL CENTER 3501 HWY 190 EAST EUNICE, LA 70535 LOUISIANA LAW (LSA R.S. 40:44) PROVIDES THAT A CERTIFICATE OF EVERY CHILD’S BIRTH BE FILED WITH THE REGISTRAR OF VITAL RECORDS WITHIN FIFTEEN (15) DAYS AFTER BIRTH. FOR BIRTHS THAT OCCUR WITHIN A HOSPITAL OR EN ROUTE THERETO, THE LAW (LSA R.S. 40:45) REQUIRES THAT THE HOSPITAL PREPARE THE BIRTH RECORD. IN ADDITION TO THE MEDICAL INFORMATION NORMALLY MAINTAINED BY YOUR HOSPITAL, THE BIRTH REGISTRATION AUTHORITY REQUIRES THAT DETAILED INFORMATION BE COLLECTED ABOUT THE MOTHER AND THE FATHER. THAT INFORMATION MUST BE PROVIDED BY THE PARENTS OR SOME OTHER PERSON WHO IS KNOWLEDGEABLE ABOUT THE PARENTS. LOUISIANA VITAL STATISTICS LAW ESTABLISHES SEVERE PENALTIES (LSA R.S. 40:61) IN TERMS OF BOTH FINES AND IMPRISONMENT FOR ANY PERSON CONVICTED OF WILLFULLY AND KNOWINGLY MAKING FALSE STATEMENTS INTENDED FOR USE IN PREPARING A BIRTH RECORD OR WHO REFUSED TO PROVIDE THE REQUIRED INFORMATION. IF THE CERTIFICATE IS RETURNED DUE TO ERRORS MADE BY THE HOSPITAL AND A DELAYED CERTIFICATE MUST BE ISSUED THE HOSPITAL WILL TAKE FULL RESPONSIBILITY AND PAY BOTH THE FEE FOR THE DELAYED CERTIFICATE AS WELL AS THE NOTARY FEE. IF THE CERTIFICATE IS RETURNED DUE TO ERRORS MADE BY THE PARENT OR THE PARENT FAILS TO COMPLETE THE CERTIFICATE WITHIN 15 DAYS OF BIRTH OF CHILD AND A DELAYED CERTIFICATE MUST BE ISSUED THE PARENT WILL TAKE FULL RESPONSIBILITY AND PAY BOTH THE FEE FOR THE DELAYED CERTFICATE AS WELL AS THE NOTARY FEE. I certify that I have read and understand the above statement. _____________________________________________________________ __________________ Signature of parent or authorized person Date PLEASE PRINT AND COMPLETE ALL INFORMATION REQUESTED MOTHER’S INFORMATION: FULL COMPLETE NAME ______________________________________________________________________________ MOTHER’S FIRST MIDDLE LAST (maiden if married) ____________________________________ ______________________ MOTHER’S CITY AND STATE OF BIRTH DATE OF BIRTH _________ LAST GRADE COMPLETED IN SCHOOL OR # OF COLLEGE YEARS _ ________ AGE AT TIME OF INFANT BIRTHS __________________________ _________________ __________________________ SOCIAL SECURITY NUMBER RACE PHONE NUMBER ___________________________________________________________ _______________________ MOTHER’S ADDRESS (PHYSICAL/PO BOX) CITY STATE ZIP PARISH (PERMANENT FOR ONE (1) YEAR) FOR ACKNOWLEDGMENT OF PATERNITY AFFIDAVIT ONLY. IF YOU ARE CURRENTLY MARRIED TO THE FATHER OF THE CHILD PLEASE DISREGARD. _________________________________ __________________________ MOTHER’S EMPLOYER (NAME) MOTHER’S OCCUPATION ________________________________________________________________________________________ EMPLOYER’S ADDRESS ________________________________________________________________________________________ MOTHER’S GUARDIAN (IF MOTHER IS UNDER 18) (NAME & ADDRESS) WERE YOU MARRIED AT TIME OF BIRTH? YES OR NO IF YOU WERE NOT MARRIED BUT DIVORCED PLEASE INDICATE DATE OF DIVORCE. _____________________ IF YES(MARRIED), _________________________________________________________________________ FULL NAME OF HUSBAND AND HIS ADDRESS DO YOU HAVE HEALTH INSURANCE? YES OR NO IF YES, ______________________________________________________________________________ NAME OF COMPANY AND POLICY NUMBER DO YOU HAVE MEDICAID (HEALTH CARD)? YES OR NO FATHER’S INFORMATION: FULL COMPLETE NAME ______________________________________________________________________________________ FATHER’S FIRST MIDDLE LAST _________________________________________________ ________________________________ FATHER’S CITY AND STATE OF BIRTH DATE OF BIRTH __________ LAST GRADE COMPLETED IN SCHOOL OR # OF COLLEGE YEARS ___________AGE AT TIME OF INFANT BIRTH ___________________________ ____________________ ____________________________ SOCIAL SECURITY NUMBER RACE PHONE NUMBER ___________________________________________________________ ___________________________ FATHER’S ADDRESS (if same as mother’s leave blank) PARISH FOR ACKNOWLEDGMENT OF PATERNITY AFFIDAVIT ONLY. IF YOU ARE CURRENTLY MARRIED TO THE FATHER OF THE CHILD PLEASE DISREGARD. __________________________________________ ________________________________ FATHER’S EMPLOYER (NAME) FATHER’S OCCUPATION EMPLOYER’S ADDRESS ______________________________________________________________________________________ FATHER’S GUARDIAN (IF FATHER IS UNDER 18) (NAME & ADDRESS) DO YOU HAVE HEALTH INSURANCE? YES OR NO IF YES, ________________________________________________________________________________ NAME OF COMPANY AND POLICY NUMBER IF FATHER IS UNDER 18 HIS GUARDIAN’S SIGNATURE WILL BE REQUIRED ON THE ACKNOWLEDGMENT FORM IN ORDER FOR IT TO BE COMPLETE. DO YOU HAVE ANY OTHER CHILDREN? YES OR NO (DO NOT COUNT THE ONE BORN TODAY) IF YES, HOW MANY? __________ WHAT IS THE DATE OF BIRTH OF THE LAST CHILD? __________ (DO NOT COUNT THE ONE BORN TODAY) HAVE YOU HAD ANY CHILDREN DIE AFTER BIRTH? YES OR NO IF YES, HOW MANY? __________________ HAVE YOU EVER HAD ANY MISCARRIAGES, STILLBIRTHS OR ABORTIONS? YES OR NO IF YES, HOW MANY?___________ WHAT IS THE DATE OF LAST MISCARRIAGE, STILLBIRTH OR ABORTION? __________________________ MONTH AND YEAR ------------------------------------------------------------------------------------------------------------------------------------ WOULD YOU LIKE TO APPLY FOR THE SOCIAL SECURITY NUMBER THROUGH THE BIRTH CERTIFICATE? YES OR NO WOULD YOU LIKE THE BABY’S BIRTH ANNOUNCEMENT PRINTED IN THE NEWSPAPER? YES OR NO IF YOU KNOW WHAT THE BABY’S NAME WILL BE PLEASE COMPLETE: PLEASE PRINT FULL NAME INCLUDE IF BABY WILL BE (Jr., II, or III) ______________________________________________________________________________ BABY’S LAST NAME FIRST NAME MIDDLE NAME
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