Notification of Pregnancy
The earliest possible completion of this form allows us to best use our resources and services to help you or your patient achieve a healthy pregnancy outcome. If you have any questions completing this form, please call 1-855-242-0802, TTY/TDD 711.
This form was completed by:
Date Of Birth
Date of first Prenatal Visit
Race/Ethnicity (fill in all that apply)
American Indian/Native American
Number of Full Term Deliveries
Number of Stillbirths
Number of Pre-Term Deliveries
Number of Miscarriages/Abortions
Pregnancy Risk Assessment
If there are no known risk factors, please check this box
Are any of the following risk factors present?
History (fill in all that apply):
Current Pregnancy (fill in all that apply):
Previous Pre-Term (<37 weeks) delivery?
If yes, was the delivery spontaneous?
Is the member a candidate for progesterone injections?
Pre-Term labor this pregnancy?
Recent delivery (within the past 12 months)?
Shortened Cervix <23 weeks this pregnancy?
Cervical Cerclage placement?
Diabetes (prior to pregnancy)?
Current severe hyperemesis?
Current mental health concerns?
High Blood Pressure (prior to pregnancy)?
Current tobacco use?
Current alcohol use?
Seizure within the last 6 months?
Current street drug use?
Previous alcohol or drug abuse?
OB Provider Name: