Fox & Cub Doula Certification Form

Please complete this form to share your qualifications, certifications, and professional experience. This information helps ensure Fox & Cub maintains the highest standards of care and exceptional service for our private-pay clients, health plans, and insurance partners.

1. First Name *

2. Last Name *

3. Street Address *

Instruction: Enter numbers and street name only (include unit or apartment number if applicable).

4. City *

5. State *

6. Zip Code *

7. County *

8. Legal Business Name (if applicable)

9. DBA (Doing Business As), if applicable

10. TIN/EIN (if applicable)

11. What are your pronouns *

12. Email *

13. Phone Number *

14. Date of Birth *

15. Website or Instagram Profile *

16. Cities/Counties Served *

17. Which area of California do you live in and provide the majority of your doula services?

Northern California (Alameda, Contra Costa, Fresno, Kings, Madera, Marin, Napa, Sacramento, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, and surrounding counties)

Southern California (Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Ventura, and surrounding counties)

18. What is your ethnicity?

19. Are you Trust Line Certified? If yes, upload the certification below. *

Yes

No

20. Upload the Trust Line Certification (Do not include a google drive link, only jpg, png, or pdf accepted)

Maximum file size: 100 MB

21. How many years of experience do you have? *

22. What are your hourly rates for postpartum doula support? Please list your daytime and overnight rates separately. If you do not provide postpartum support, please enter “N/A”. *

(Example: Daytime: $45/hour | Overnight: $55/hour)

23. What are your birth doula package price(s), and what does each package include? Please list the number of prenatal visits, postpartum visits, and any additional support or services provided. If you are not a birth doula, please enter “N/A”. *

24. What doula certification(s) do you hold? If full-spectrum, you will be able to work with insurance patients. If not, no worries, you can work with our private-pay clients. *

25. Please upload copies of your certification(s). (Do not include a google drive link, only jpg, png, or pdf accepted) (Note: Please only one file upload per question. There will be more opportunities further down on form to upload your other documents.) *

Maximum file size: 100 MB

26. Do you have an additional image/file to upload from the question above?

Maximum file size: 100 MB

27. Are you in-network with any health plans and/or organizations? If so, please list below

(MediCal, Kaiser, Anthem, etc) *

28. Are you CPR certified from from the American Red Cross (ARC) or American Heart Association (AHA)?*If you are not, here is a link to get it done: https://www.redcross.org/local/california/take-a-class/cpr

Yes

No

Scheduled

29. Please upload a copy of your CPR certification (Do not include a google drive link, only jpg, png, or pdf accepted) *

Maximum file size: 100 MB

30. Do you have HIPAA training certification? *

If you do not have HIPAA Training, please complete the course by completing this FREE course: https://www.nephtc.org/enrol/index.php?id=178

Yes

No

In Progress

31. Please upload a copy of your HIPAA certification (if applicable) (Do not include a google drive link, only jpg, png, or pdf accepted) *

Maximum file size: 100 MB

Other Specialites

33. Are you on the pave portal? *

Yes

No

34. If you are Medi-Cal Approved, please upload your Medi-Cal/DHCS approval letter. (Do not include a google drive link, only jpg, png, or pdf accepted)

Maximum file size: 100 MB

35. If you are not Medi-Cal approved, would you like assistance in getting Medi-Cal approved? *

Yes

No

I want to learn more about the process

36. Do you have additional certifications? (eg. lactation support, childbirth education...) *

37. If yes to the above question, please upload any additional copies of certifications. (Do not include a google drive link, only jpg, png, or pdf accepted)

Maximum file size: 100 MB

38. Do you have an additional image/file to upload from the question above?

Maximum file size: 100 MB

39. How many families have you supported? *

40. What languages besides English do you speak if any? *

Other Option

42. Please write your bio down below. *

43. What is your philosophy or approach to prenatal, birth, and postpartum support? This is an open ended question, feel free to take it however you like. *

44. Please upload a headshot for us to use on your profile page. (Do not include a google drive link, only jpg, png, or pdf accepted) *

Maximum file size: 100 MB

45. How do you prefer to engage with your patients? (Check all that apply) *

In Person

At their Residence

Virtually

At the hospital

46. Will you support clients & patients IN-PERSON during labor + delivery *

Yes

No

47. Are you on the Carrot directory? *

Yes

No

48. Are you comfortable encouraging vaccinations for both mom, child, and family members? We encourage and educate patients to stay up to date on their vaccinations so want to understand if you are aligned with our mission. *

Yes

No

Other

Other Option

50. Please list your National Provider Number (NPI) for yourself below. If you do not have one, please take 5 minutes and get one using this website: https://nppes.cms.hhs.gov/#/ *

51. Enter your SSN (required only for those already on pave portal and wanting to work with insurance patients)(Your Social Security number is required for insurance billing and credentialing purposes only. It is kept confidential and securely protected.)

52. Last 4 digits of SSN (only required if you plan to support clients using insurance benefits).

Your information is kept secure and confidential and is used solely for insurance credentialing and billing purposes. It will never be shared outside of authorized billing and credentialing processes.

53. If you have any kind of insurance associated with your practice please upload them below (We do require individual insurance) (upload directly as a pdf or png, not from drive) *

Maximum file size: 100 MB

54. Were you referred by anyone? *

55. Please write down any questions, comments, or concerns you may have, and we will get back to you as soon as possible. *

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