prenatal_incentive_form

Prenatal Incentive Registration and Referral Form

This form is to be completed for Blue Choice Option, HMOBlue Option, Blue Option Plus, Premier Option,Premier Option Plus, Premier Child Health Plus and Child Health Plus members only.

This form is to be completed for Blue Choice Option, HMOBlue Option, Blue Option Plus, Premier Option,Premier Option Plus, Premier Child Health Plus and Child Health Plus members only.

Date Completed

Date Completed mm/dd/yyyy null

Date of First Prenatal Visit

Date of First Prenatal Visit mm/dd/yyyy null

Demographics

Demographics

Patient Name

Patient Name First and Last Name null

Date Of Birth

Date Of Birth mm/dd/yyyy null

Subscriber ID

Subscriber ID 9 digit number or 'M' followed by 8 digits null

Street Address 1

Street Address 1 Street Address/P.O. Box null

Street Address 2

Street Address 2 Apartment/Suite/Unit/Building/Floor

City

City null

State

State null

Zip Code

Zip Code 5 digit zip code null

Phone Number

Phone Number ###-###-#### null

Estimated date of confinement

Estimated date of confinement mm/dd/yyyy null

Diagnosis

Diagnosis null

Type of pregnancy

Type of pregnancy null

Gravida

Gravida

Para

Para

Registered for Prenatal Care

Registered for Prenatal Care

Weeks by LMP/Ultrasound

Weeks by LMP/Ultrasound

Race

Race

Billing Information

Billing Information

Primary Prenatal Care Provider

Primary Prenatal Care Provider First and Last Name of Provider null

NPI

NPI 10 digit National Provider Identifier null

Provider Phone Number

Provider Phone Number ###-###-#### null

Hospital (for delivery)

Hospital (for delivery) Hospital name null

Date of First Prenatal Visit

Date of First Prenatal Visit mm/dd/yyyy null

Trimester

Trimester null

I - Social Risk Factors

Automatic referral if four or more risk factors from this category or for active domestic violence

I - Social Risk Factors

Automatic referral if four or more risk factors from this category or for active domestic violence

Social Risk Factors

Social Risk Factors

Is Physical/Sexual Abuse a Current Problem?

Is Physical/Sexual Abuse a Current Problem?

For II, III and IV, automatic referral if five or more risk factors identified from all three categories combined


II - Maternal Medical History

For II, III and IV, automatic referral if five or more risk factors identified from all three categories combined


II - Maternal Medical History

Maternal Medical History

Maternal Medical History

III - Psycho-Neurological History

Automatic referral if desires counseling, current substance abuse or mentally/physically challenged

III - Psycho-Neurological History

Automatic referral if desires counseling, current substance abuse or mentally/physically challenged

Psycho-Neurological History

Psycho-Neurological History

Previous Counseling Evaluation or Treatment,

Previous Counseling Evaluation or Treatment,

For How Long?

For How Long?

Substance/Alcohol Abuse Hx.

Substance/Alcohol Abuse Hx.

List Substances

List Substances

Mentally/Physically Challenge

Mentally/Physically Challenge

Describe Mental/Physical Challenge

Describe Mental/Physical Challenge

IV - Maternal Obstetrical History

Automatic referral for any history or current PTL or <12 months between births

IV - Maternal Obstetrical History

Automatic referral for any history or current PTL or <12 months between births

Maternal Obstetrical History

Maternal Obstetrical History

Previous Uterine Surgery

Previous Uterine Surgery

Describe

Describe

Tocolytics Used

Tocolytics Used

Used at How Many Weeks Gestation

Used at How Many Weeks Gestation

Eating Disorder

Eating Disorder

List Disorder(s)

List Disorder(s)

V - Previous Infant/Findings

Automatic Referral for any history of preterm birth or stillbirth

V - Previous Infant/Findings

Automatic Referral for any history of preterm birth or stillbirth

Previous Infant Findings

Previous Infant Findings

Other previous infant findings

Other previous infant findings

 

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