State of Illinois
Department of Human Services
RECORD OF BIRTH
IL 444-2636 (R-02-14) Record of Birth Printed by Authority of the State of Illinois Page 1 of 1
-0- Copies
3 (PERMANENT)
Check this box if you need the child added immediately due to services other than delivery.
1. Case Name:
2. Case Number:
3. Name of Hospital:
4. Hospital Address:
5. Baby's Full Name:
7. Date of Birth: Sex:
Date:
DeathAdoption
6. If multiple birth, name(s) of birth sibling(s):
9. Mother's Full Name: Maiden:
10. Mother's Social Security Number: Mother's birth date:
11. Mother's Recipient Number: Mother's Phone Number:
12. Mother's Address:
13. Father's Full Name:
14. Father's Social Security Number: Father's Birthdate:
15. Father's Address:
Hospital Contact Person (Print Name) Authorized Signature of Hospital Staff
Date
Hospital Contact's Phone Number
Instructions to Hospital
Medical Assistance is authorized for a child born to a Medical Assistance recipient when the Department of Human Services
becomes aware of the birth. To begin the process for a child born in your hospital:
* Complete all items below. Please print clearly or type.
* Be sure to include the name and phone number of a hospital contact person for confirmation.
* Send with this form a copy of Form 3416B, Voluntary Acknowledgment of Paternity, if it was completed at the hospital for the
child.
* FAX the forms to (217) 785-8113 or mail to the Newborn Unit, 100 S. Grand.Ave. E., Springfield, IL 62762
Send forms soon after the birth to avoid a delay in authorizing Medical Assistance for the child.
Last First Middle
Street City State Zip
Last First Middle
or
Last First Middle
Street City State Zip
Last First Middle
Street City State Zip
8. If applicable, provide date of child's
This form is authorized pursuant to 89 Ill. Adm. Code 120.11. Completion of the form is voluntary and there are no penalties for
failure to do so.
