Follow the steps to complete the Obstetrical Service Request Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the reference number and start and end dates, as this information is essential for processing your request.
3. In the ‘Member Information’ section, provide the necessary details such as the member's name, date of birth, and identification number. Be sure to include the correct address.
4. If the request involves a minor, mark the appropriate box and include the parent or guardian's name.
5. In the ‘Procedure/Service Information’ section, indicate the service being requested and provide the relevant ICD-9, CPT, and HCPC codes as needed.
6. Enter the last menstrual period (LMP), gravidity (Gravida), expected due date (EDD), and other relevant prenatal statistics including any high-risk factors.
7. Mark any applicable health history checkboxes related to the patient's condition, including gestational diabetes or other specified conditions.
8. Complete the ‘Provider Information’ section by entering the requesting provider's details, including their name, whether they are in-network, and contact information.
9. Finally, ensure that the requesting provider or authorized person signs and dates the form to confirm submission.
10. Review all entries for completeness and accuracy before saving the changes, downloading, printing, or sharing the completed form.

Complete your Obstetrical Service Request Form online today for a seamless experience.