Prenatal Notification Form - Providers - Prestige Health ... - HIE Networks

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Please call Bright Start or fax an updated form if the member has any changes in condition during pregnancy. This update
Prenatal Notification Form

To submit requests, please fax completed form to 1-855-358-5852 If you have any questions please call 1-855-371-8076

HE A LTH CHOICE ® Leading the Way to Quality Care

Provider Information Provider’s Name: Tax ID: Phone:

Fax:

Address, City, State Zip:

Member Information Member Name:

Medicaid ID Number:

Member DOB:

Phone:

Language Preferred:

Address, City, State Zip: Tobacco Use Average number of cigarettes smoked per day. If none enter 0; 1 pack = 20 cigarettes Pre-Pregnancy: 1st Trimester: 2nd Trimester: 3rd Trimester:

Pregnancy Information & History Date of First Prenatal Visit:

17-P Candidate

EDC :

Gravida:

Para:

Induced

Three consecutive abortions:

Gest. Age:

Abortions: Spontaneous

Last Pregnancy

Yes

No

Pre-term:

Living:



Low birth weight 20 weeks

STD history



Gestational diabetes

Premature ROM

Pre-eclampsia/Eclampsia

Postpartum depression



Classical incision/C-section

IUGR

Hx of DVT/PE

Pre-term delivery gest.

Congenital anomaly: Other (specify)

Current Pregnancy

Multiple gestation:

Twins

Triplets

Other



Pre-eclampsia

Eclampsia

Premature labor

Diabetes



RH sensitization

Renal disease

Placenta previa

Heart disease



Sickle cell disease

Abnormal ultrasound

Premature rupture of membranes

Hypertension



Incompetent cervix

Alcohol or drug problems

STD

Poor weight gain



IUGR

2nd/3rd trimester bleeding

Periodontal disease

PIH



Previous delivery within 1 year of EDC

Late and/or inconsistent prenatal care\Seizure disorder



Asthma

No current risk

HIV

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P2044_1401

Pregnancy Information & History continued Active Mental Health Conditions

No mental health conditions



Other (specify)

Schizophrenia

Bipolar

Depression

Intellectual impairment

Social, Economic and Lifestyle Issues

No identified social, economic or lifestyle issues

Eating disorder



Homelessness

Substance abuse (specify type)



Mental/physical/sexual abuse (current or hx. of)

Opiod therapy

Please call Bright Start or fax an updated form if the member has any changes in condition during pregnancy. This updated information can assist Bright Start with member outreach.

Internal Use Only: Maternity Authorization # Covering dates of service

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