Get Pregnancy Notification Form

The Pregnancy Notification Form is a crucial document that aids in identifying members who are pregnant and might require additional support. Completing this form online ensures that the information is submitted efficiently and accurately.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the Pregnancy Notification Form and open it in the editing tool.
2. Fill in the member’s name, date of birth, and member ID in the designated fields. Ensure that the information is correct to avoid any discrepancies.
3. Provide the member’s current phone number and address. If applicable, enter the member’s school information.
4. Enter the physician’s name and contact information, including the phone number and fax number of the office contact person.
5. Fill out the Gravida/Para/Ab/Living details and the expected date of delivery. This information is essential for understanding the member’s pregnancy history.
6. Select any risk factors applicable to the member by checking the appropriate boxes. You can indicate multiple risk factors, or select 'NO Risk Factors' if applicable.
7. Complete the section on the date of the first office visit with the physician and the weeks of gestation at that visit. This provides context for the medical care timeline.
8. Indicate whether there has been previous prenatal care, including where it was received and the date of the first prenatal visit.
9. Fill in the Body Mass Index (BMI) of the member, which is relevant for assessing health risks during pregnancy.
10. If applicable, confirm whether the pregnant teenage member has authorized the release of information to their parents by selecting 'Yes' or 'No.'
11. If social work intervention is required, provide additional relevant information in the designated section.
12. After ensuring all required fields are accurately completed, review the form for any errors. Once verified, you can save changes, download, print, or share the form as needed.

Complete your Pregnancy Notification Form online today to ensure timely support and assistance.