Newborn Health Record Checklist - Mountain Midwifery Center

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Mountain Midwifery Center
Newborn Health Record Checklist
Parent directions: The top part of this form should be filled out by the parents-to-be and given to MMC by the 36-week visit.
Mother’s Full Name: ____________________________________ DOB: ______________
Partner’s Full Name: ____________________________________
Residence farther than 40 driving miles of MMC? YES / NO
If YES, please provide initial postpartum location, if not home address.
Postpartum Location _________________________________ Within 20 verified driving miles? (attach map)
_________________________________ YES/NO
Choice of Early Postpartum Care (circle one):
-
2 Day office visit
-
1 Day office visit with 2-3 day newborn
follow-up with non-MMC provider
Is the Birth Certificate Worksheet complete? YES / NO
If NO, comment: _________________________
Reminder: If parents not married at time of birth, please attach Acknowledgement of Paternity.
Newborn Primary Care Provider
Name: ___________________________________ Type: ___________________
(Fam Prac MD, DO, Pediatrician MD, etc.)
Reminder: MMC will need an Authorization to Disclose Health Information for newborn records release.
Newborn’s Insurance – Name: _______________________________________________________________
Policy Holder: ________________________________
Relation to Newborn: _______________________
Subscriber # __________________________________
Group # __________________________________
Subscriber DOB:___________ Copay Amount: ________ Deductible: ________ Coinsurance: ___________
Midwife & RN Directions: After birth, Midwife completes info below. After discharge, RN places chart on front desk in Ste 500.
Baby’s Name:____________________________________
Date & time of birth (as reflected on mother’s labor flow sheet): ___________________________
-
Newborn Insurance – Copy of card in chart? YES / NO / SAME AS MOTHER
-
2-day Postpartum visit
Date for visit ________________
Time _____________________________
-
Provider (RN, CNM): ______________________________
Contacted by CNM: _________________
Is the Birth Certificate Worksheet complete? YES / NO
If NO, comment: _________________________
Front Desk Directions: Please complete and retain in the chart, newborn section, on top.
Schedule 1-week Postpartum visit. Date: ___________________ Time____________________
Date birth certificate filed: ___________________ Cert # ___________________

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