The BirthPlace offers pre-admission registration so that the joy of your special moment is not tempered by the stress of last-minute details. We encourage you to complete and return this Pre-Admission form as soon as possible during your pregnancy. Additionally, please read and sign the Condition of Services forms - one for you and one for your baby. Complete the other steps noted in the Pre-Admission Checklist below.
Once we receive your completed forms, we will finish the pre-admission process by entering your information into our computer system and contacting your insurance company for verification. PLEASE NOTE THAT WE NO LONGER SEND PATIENT IDENTIFICATION CARDS TO EXPECTANT PARENTS. We will, however, send an acknowledgement after receiving your forms.
When your doctors office instructs you to come to our hospital after labor begins, please go directly to our Labor & Delivery Unit. Remember to bring your insurance card with you to our hospital.
To complete the pre-admission process for The BirthPlace, please follow all of the steps listed below:
1) Print and complete the Pre-Admission Registration form (see below). If you have not yet selected a pediatrician for your baby, please note TBD (to be decided) in the space after "Pediatrician."
2) Print and complete two Terms and Conditions of Service forms -- one for you and one for your baby -- and sign them. (If you're expecting multiples, you must complete a form for each baby.) For the "Relationship of Representative to Patient" section underneath the signature, note "Self" on your form, and "Mother" on baby's form.
3) Before completing the section about "Advance Directives" on the Terms and Conditions of Service forms, read the "Patient Rights and Responsibilities" section of our website, as well as the document below titled "Your Right to Make Decisions about Medical Treatment." It will help you better understand and answer the questions in this section.
4) Do NOT complete the "Advance Directives" section on your baby's form. Draw a line through it and note "Minor".
5) Mail all of the above documents with your insurance form or a copy of your insurance card (both sides) to:
UCLA Medical Center, Santa Monica
The BirthPlace Office
1250 16th Street
Santa Monica, CA 90404
6) If you have a completed Advance Directive, please enclose a copy with these forms.
7) Mail completed forms at least two months before your due date.
PLEASE NOTE: WE NO LONGER ACCEPT FAXED COPIES OF THE TERMS AND CONDITIONS OF SERVICE FORM AS ORIGINAL SIGNATURES ARE REQUIRED.
* For a brochure with more information about advance directives, or the actual form, please call our BirthPlace Office at (424) 259-8250.
Notice of Privacy Practices Notice of Privacy Practices_English.pdf
Aviso de Practicas de Privacidad Notice of Privacy Practices_Spanish.pdf