Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient/member's name and member ID number at the top of the form. Ensure all information is clearly printed or typed.
3. Fill in the provider's name and the patient's date of birth (DOB). Next, provide the expected date of delivery (EDD) and the number of fetuses.
4. Record the date of the first prenatal visit, gravida, and para information. Additionally, confirm if a social service or community outreach referral has been made.
5. Enter the patient's address, and then provide both the provider’s telephone and fax number, as well as the provider billing number.
6. Include the provider's email address and the National Provider Identifier (NPI). Also, provide the patient’s telephone number along with their cell phone number.
7. Complete the date and agency fields at the bottom of the form. Note if there is other insurance information available for the patient.
8. In the Factors I section, indicate any relevant medical history or current pregnancy factors that place the patient at risk by checking the corresponding boxes.
9. If applicable, complete Factors II by identifying any additional conditions or situations that may place the patient at risk.
10. Provide detailed obstetrical history if relevant, indicating any congenital anomalies or previous infant deaths.
11. Fill in the form completed by section and the physician's signature at the end, including the date of completion.
12. Once all information is filled out, save changes, download, print, or share the form as needed. Ensure to fax it to Molina Healthcare at 1 866 504 7256.

Complete the Pregnancy Risk Assessment in Healthcare form online today for a proactive approach to prenatal care.