Once you complete 6 prenatal visits with Dell Children’s Health Plan, you will be eligible to receive a voucher for a convertible car seat at a Dell Children’s Simply Safety Center. Download and print this form, bring it to each prenatal visit, and have your doctor date and initial the table below with the appointment type. Remember, ultrasound appointments do not count toward your 6 visits!

After your 6^th visit, please email a copy or picture of the form, your name, phone number and CHIP or STAR Medicaid ID to DCHPMarketing@ascension.org to receive your voucher and instructions to get your convertible car seat. If you have any questions or need help, please call Member Services at 1-855-921-6284 (TTY 7-1-1).