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Pregnancy Assessment Form Name Address City State Zip Phone Date of Birth Member ID Current Weight Obstetric Provider Provider Phone Fax EDC G P Date of First Prenatal Visit Delivering Hospital Referral Number This section should be completed by the member and reviewed by the health care provider. X Risk Factors Comments Previous preterm delivery Number of preterm deliveries 37 weeks gestation Gestational age at delivery 17P Candidate Requested start date Multiple gestation this pregnancy Twins triplets etc* High blood pressure Chronic or history with previous pregnancy Diabetes Type 1 Type 2 Previous gestational diabetes Coagulation disorder Use of or Reason History of incompetent cervix Cerclage Current tobacco use Quit date Current alcohol use Current drug use Domestic violence or other psychosocial issue Best time and number for contact Genitourinary complications History of kidney stones or urinary tract infection Second delivery in less than one year Date of delivery Younger than....

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A woman's claim or self-declaration of pregnancy may be used as proof of pregnancy. b. A short certification of up to 60 days may be assigned, and benefits issued, for applicants who self-declare pregnancy.

The pregnancy verification form is a letter that is used to show proof of a positive pregnancy test, confirming that the woman is indeed pregnant. The form details the date when the individual visited the clinic/hospital, the estimated date of delivery, and any additional notes or comments related to the test.

Pregnant women are usually given priority in determining Medicaid eligibility. Most offices try to qualify a pregnant woman within about 2-4 weeks. If you need medical treatment before then, talk with your local office about a temporary card.

If you get a positive result, you are pregnant. This is true no matter how faint the line, color, or sign is. If you get a positive result, you may want to call your doctor to talk about what comes next. In very rare cases, you can have a false-positive result.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232