Get Gems Self Referral Form English Revised - Horizon Nj Health

The GEMS Self Referral Form is a critical document for individuals seeking early maternity services with Horizon NJ Health. This guide provides clear, step-by-step instructions for filling out the form online, ensuring a seamless experience for all users.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the GEMS Self Referral Form and open it in a suitable editor.
2. Fill in your personal information in the 'Tell us About Yourself' section. This includes your name, today's date, Horizon NJ Health ID number, date of birth, address, and phone numbers.
3. Indicate your doctor’s name and due date. Additionally, specify who will be the pediatrician for your baby after delivery.
4. Answer the question regarding financial problems by selecting 'Yes' or 'No,' and provide an explanation if applicable.
5. In the 'Tell us About Your Pregnancy' section, detail the number of pregnancies you have had, noting whether you have experienced any complications during the current pregnancy.
6. Respond to questions regarding past childbirth incidents, high blood pressure, diabetes, mental health issues, and substance use. Be sure to provide explanations where 'Yes' is selected.
7. Answer whether you are now or have ever been a victim of physical or sexual abuse and indicate your plans regarding breastfeeding.
8. Provide the best contact method to reach you for follow-up communications.
9. Write any additional comments or requests for information needed.
10. Review the completed form for accuracy and clarity, then save any changes.
11. Submit the form by emailing it to Mom’s_GEMS@horizonblue.com or by faxing it to the confidential fax line at 1-609-583-3024.
12. For further questions, contact Mom’s GEMS at 1-609-718-9321 (TTY: 1-800-654-5505).

Complete the GEMS Self Referral Form online to access vital maternity services.