Pregnancy Notification
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1FAST FAX
Pregnancy Notification
(First Prenatal Visit)
POLICY REMINDER: Submit claim code V72.42 to be reimbursed for the pregnancy
confirmation office visit in addition to the global obstetrical package.
Please send fax to 866-549-8598
Type of Referral:
Plan Type:
❑
❑
Pregnancy Notification
UnitedHealthcare Member
❑
❑
17P Administration Nursing Service
UnitedHealthcare SignatureValue™ Plan Member
❑
❑
Miscarriage/Termination Notification
All Other Members
Member ID #: _________________________________________ Group #: ________________________________________
Patient Name: __________________________________________________________________________________________
Street Address: __________________________________________________________________________________________
City/State: _____________________________________________________________________________________________
Phone: ________________________________________________________________________________________________
Date of Birth: ___________________________________________________________________________________________
EDC: _________________________________________ Gestational Age (GA): _____________________________________
17P Administration Nursing Service
❑
Pharmacy-Compounded, Preservative-Free 17P Therapy
Please indicate individual patient medical need for a pharmacy-compounded, preservative-free formulation
❑
Documented history of previous spontaneous preterm birth
❑
Current pregnancy at risk for preterm birth
❑
Sensitivity to preservatives
❑
Specific sensitivity to benzyl alcohol
❑
Other: _____________________________________________________________________________________
Physician: _____________________________________________________________________________________________
Street Address: __________________________________________________________________________________________
City/State/Zip: __________________________________________________________________________________________
Phone: _________________________________________________________________________________________________
Physician Plan ID #: ______________________________________________________________________________________
Signature (required if ordering 17P Administration Nursing Service):
_______________________________________________________________________________________________________
T
HE INFORMATION CONTAINED IN THIS FACSIMILE IS CONFIDENTIAL AND INCLUDES PROTECTED PATIENT HEALTH INFORMATION. THE
INFORMATION IS INTENDED ONLY FOR THE USE OF UNITEDHEALTHCARE AND ITS DESIGNEES.
IF YOU ARE NOT THE INTENDED RECIPIENT OR THE EMPLOYEE OR AGENT RESPONSIBLE TO DELIVER IT TO THE INTENDED RECIPIENT, YOU
ARE HEREBY NOTIFIED THAT ANY USE, DISCLOSURE, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU
HAVE RECEIVED THIS FACSIMILE IN ERROR, PLEASE IMMEDIATELY NOTIFY US BY TELEPHONE AT (888) 936-7246 AND RETURN THE ORIGINAL
MESSAGE TO US AT UNITEDHEALTHCARE, 5901 LINCOLN DRIVE, EDINA, MN 55436. THANK YOU.
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