Follow the steps to successfully complete the notification form

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. In the member information section, fill in the first name, middle initial, last name, member’s date of birth, member ID number, estimated date of delivery, trimester of pregnancy, date of first visit, gravida, para, last menstrual period, address, city, state, ZIP code, and phone numbers.
3. Complete the provider information section by entering the first name, middle initial, last name, provider ID number, address, city, state, ZIP code, practice phone number, and fax number.
4. In the provider reason for referral section, check all applicable medical and psychosocial conditions related to the current pregnancy, such as diabetes mellitus, preterm labor, or domestic violence.
5. If applicable, indicate whether the individual has a history of preterm labor/delivery, c-section delivery, or other relevant medical histories by marking 'H' for history and 'C' for current.
6. Include any additional concerns in the 'Other Obstetrical/Medical/Social Determinant Concerns' section, if necessary.
7. Obtain the provider signature/stamp and date the form to complete the submission process.
8. Once all information is filled out correctly, users can save changes, download, print, or share the completed form as needed.

Take the first step in your maternity care management by completing the necessary documents online today.