2025 Doula Care Form

A doula is a trained professional who provides emotional, physical and educational support to a mother who is pregnant, is in labor or has recently given birth.

Complete this form if you would like to request more information about doula services OR to claim your $50 gift card for the doula care incentive.

To be eligible for the gift card, you must be a Priority Health Medicaid member. You must complete at least four visits with a doula before birth. Doula services are covered at no cost to you. Your gift card will be delivered via email.

Rewards are only offered for actions taken within the current year. Rewards cannot be applied retroactively for actions taken in previous years.

Personal Information

1. Full Name *This question is required.

2. Please enter your Priority Health Contract ID (found on the front of your Priority Health Member ID card) or Medicaid ID (found on the front of your mihealth card). *This question is required.

3. Please re-enter your Priority Health Contract ID or Medicaid ID *This question is required.

4. Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Phone Number *This question is required.

6. Active Email Address *This question is required. This question requires a valid email address.

7. Mailing Address *This question is required.

Doula Services

8. Are you submitting this form to request more information about doula services?

I am interested in learning more about:

How to find a doula
Eligibility and coverage information for doula care
What services a doula provides
Other Please enter an 'other' value for this selection.

9. Are you submitting this form to claim your $50 gift card?

Have you completed at least 4 visits with your doula?

To be eligible for the gift card, you must complete at least four visits with a doula before birth.

Please provide the first and last name of your doula. *This question is required.

Estimated Due Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Resources
Want to learn more about our no-cost maternity programs and resources? Check all that apply. Our team will contact you.

10. Preferred Language

Please enter an 'other' value for this selection.

11. I am interested in learning more about:

PriorityMOM: Receive free gifts, cost and coverage information and education to help manage your pregnancy.
PriorityBABY: Receive educational information during the first 24 months of your infant’s journey.
MIHP (Maternity and Infant Health Program): Provides regular in-home visits by a nurse, social worker or dietician.
WIC (Women, Infants, and Children Program): This health and nutrition program support your family during pregnancy and child development.
Care Management: Our care management team is available to work with you and your specific health care needs during and following pregnancy.