COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF HEALTH CARE QUALITY
99 CHAUNCY STREET
BOSTON, MA 02111-1212

Application for Maternal and Newborn Service Designation

Instructions:    Please complete a separate application for each hospital campus.

Hospital Name						

Address 							 

City/Town 					State			Zip Code								
Telephone Number (__ __ __) __ __ __-__ __ __ __ Fax Number (__ __ __) __ __ __-__ __ __ __

Campus Name						

Address 							 

City/Town					State			Zip Code								
Telephone Number (__ __ __) __ __ __-__ __ __ __   Fax Number (__ __ __) __ __ __-__ __ __ __

Hospital Contact Person

	Name:

	Title:

	Telephone Number:

Please indicate annual birth volume
Calendar years:	
2003 ________

			2004 ________
 
			2005 ________

Level III only:		Percent of all births that are low birth weight infants: _______ %

Application for Maternal and Newborn Services 
Page 2 of 2

CURRENT DESIGNATION (CHECK ONE):
		
	LEVEL I 
	
	LEVEL IB
	
	LEVEL II 	Does the existing Level II unit have a Continuous Positive 
    	Airway Pressure (CPAP) waiver?          Yes    No    
		LEVEL III

	LEVEL III (Neonatal Intensive Care Unit ONLY)	

REQUESTED DESIGNATION (CHECK ONE) (Please see attached definitions):

	LEVEL IA 

		LEVEL IB

		LEVEL IIA

		LEVEL IIB

		LEVEL III

		Freestanding Pediatric Hospital with Neonatal Subspecialty Services 
		(NEONATAL INTENSIVE CARE UNIT ONLY)

The undersigned requests Department of Public Health designation of the Maternal and Newborn Service as specified above.

Chief Executive Officer or Designee (Print Name)______________________________________

Title__________________________________________________________________________

Signature_____________________________________________________________________

Date_________________________________________________________________________