Get Gateway Health Maternity Outcome Authorization Form

This guide provides clear instructions on how to complete the Gateway Health Maternity Outcome Authorization Form online. By following these steps, you can ensure that all necessary information is accurately submitted for proper authorization.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the Gateway member number in the designated field. This is essential for identification and processing.
3. Input the Gateway member's date of birth in the format of month/day/year. Make sure this information is accurate to avoid any processing delays.
4. Fill in the member's last name, first name, and middle initial as they appear in official records.
5. Provide the name of the hospital where the delivery occurred along with the hospital provider number, if available.
6. Next, enter the name and contact information for the UR contact person, including their phone and fax number.
7. Document the attending medical doctor's last name and first name to ensure proper follow-up and coordination of care.
8. Complete the delivery information by selecting the appropriate type of delivery from the options available, which includes live birth, neonatal death, or fetal death.
9. For each birth, indicate the date of birth, birth time (in military time), gender, actual discharge date for the mother, and actual admit date.
10. Input the birth weight, Apgar scores, and gestational age for each infant. Be diligent in recording these details as they are critical for health assessments.
11. Indicate whether home health services were offered for each newborn by selecting yes or no.
12. Lastly, determine the discharge status for the mother and the infant and select the corresponding option.
13. Once all fields are completed with accurate information, you can save changes, download, print, or share the form as needed.

Complete your documentation online to ensure timely processing and follow-up care.