Get Maternity Outcome Authorization Form - Unison Health Plan

Completing the Maternity Outcome Authorization Form is an essential step for ensuring proper communication between healthcare providers following a maternity event. This guide will provide you with clear, step-by-step instructions on how to fill out the form online, ensuring a smooth submission process.

Follow the steps to complete your maternity outcome authorization form online:

1. Press the ‘Get Form’ button to access the Maternity Outcome Authorization Form and open it for editing.
2. Begin by entering the necessary personal information. Fill in the 'Member ID #' and 'Social Security #' fields accurately to identify the member.
3. Complete the 'Member Last Name' and 'Member First Name' sections. Ensure that names are spelled correctly as they appear on the membership documents.
4. Provide the name of the 'Hospital' and its 'Hospital Provider Number'. This information is critical for identifying the facility involved.
5. Fill in the 'UR/CM Contact' as well as their 'MI', 'UR/CM Phone', and 'UR/CM Fax' numbers to facilitate communication with the case management team.
6. Indicate the 'Actual Delivery' date and 'Actual Discharge' date. These dates are essential for processing the claim.
7. Enter the 'Attending MD (Last Name, First Name)' and the 'Pediatrician (Last Name, First Name),' as this provides context for the care provided.
8. Input the 'Actual Admit Date' and check if there is 'Other Insurance.' If applicable, answer 'Yes' or 'No' and provide the policy number and primary carrier details.
9. Complete the section regarding a separate authorization number, marking options for NICU admissions, transfers, and sterilization when necessary.
10. For each birth (up to two), provide the 'Date of Birth', 'Birth Time (Military)', 'Gender', 'Birth Weight (Grams)', and mark whether it's a 'Fetal Death,' 'Live Birth,' or 'Neonatal Death'.
11. Fill out the 'Mom and Baby Discharge Information' section with options for where the baby will go upon discharge and whether home health services were offered.
12. Indicate the 'Feeding Method' for the infant and provide any other relevant details such as 'Authorized Length of Stay'.
13. Review all entered information to ensure accuracy before proceeding to save changes. Users can then download, print, or share the completed form as needed.

Complete your Maternity Outcome Authorization Form online to streamline the documentation process and ensure timely care.