Total Ob Pre-Authorization Form

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TOTAL OB PRE-AUTHORIZATION
Maternal Health Risk Assessment
For questions about this form call: (800) 828-7514
Fax completed form to: (480) 760-4762
Date of Request: ______________________________
Please ATTACH A COPY OF THE PRENATAL RECORD
MEMBER INFORMATION
Name: _______________________________________ HCIC ID: _____________________________
Phone: _______________________________________ DOB: ___________________________ Age: ________
PROVIDER INFORMATION
Name: _______________________________________ NPI: _________________________________________
Phone: ______________________________________ Fax: _________________________________________
Contact Person: _______________________________ Extension: ____________________________________
US Facility___________________________________
US Facility NPI# _______________________________
*
CLINICAL INFORMATION
WIC Referral Complete
CLINICAL INFORMATION
LMP: __________ (
not known) EDD: ___________ (From
LMP
U/S)
HIV Screening Complete
LMP: _________________________ (
not known)
EDD: ___________________ (From
LMP
U/S)
Date of entry into prenatal care: __________________ Date of first Visit in Provider’s office: ________________
Date of entry into prenatal care: ___________________ Date of first Visit in Provider’s office: _______________
*Note: If all information below is found on the attached prenatal record, it is not necessary to continue.
Pre-Pregnancy Weight: ___________ (
not known)
Current Weight: ____________ Height: ___________
Pre-Pregnancy Weight: ___________ (
not known)
Current Weight: ____________ Height: ___________
History
Number
Number
(indicate if none)
History
Number
Number
(indicate if none)
(indicate if none)
Total # Pregnancies:
_________
# Living Children
_________
Total # Pregnancies:
_________
# Living Children
_________
# Deliveries after 37 0/7 weeks:
_________
# Miscarriages:
_________
# Deliveries after 37 0/7 weeks:
_________
# Miscarriages/Terminations:
_________
# Deliveries 32 0/7 – 36 6/7 weeks:
_________
# Elective terminations:
_________
# Deliveries 32 0/7 – 36 6/7 weeks:
_________
# Cesarean deliveries:
_________
# Deliveries < 32 weeks:
_________
# Cesarean deliveries:
_________
# Deliveries before 32 weeks:
_________
# VBAC deliveries:
_________
# VBAC deliveries:
_________
Condition
Current Prior
Condition
Current Prior
(Check all that apply)
(Check all that apply)
Condition
Current Prior
Condition
Current Prior
(Check all that apply)
(Check all that apply)
TWINS
PRETERM BIRTH
TWINS
PRETERM BIRTH
TRIPLETS
INCOMPETENT CERVIX
OTHER MULTIPLE_________
INCOMPETENT CERVIX
OTHER MULTIPLE_________
PLACENTA PREVIA
GESTATIONAL DIABETES
PLACENTA PREVIA
GESTATIONAL DIABETES
PLACENTAL ABRUPTION
TYPE 1 or 2 DIABETES
PLACENTAL ABRUPTION
TYPE 1 or 2 DIABETES
POST PARTUM HEMORRHAGE
PIH / PRE-ECLAMPSIA
POST PARTUM HEMORRHAGE
PIH / PRE-ECLAMPSIA
SEIZURE DISORDER
ECLAMPSIA
SEIZURE DISORDER
ECLAMPSIA
HEART DISEASE
CHRONIC HYPERTENSION
HEART DISEASE
CHRONIC HYPERTENSION
RENAL DISEASE
FETAL ANOMALIES
RENAL DISEASE
FETAL ANOMALIES
HEPATIC DISEASE
GENETIC DISORDER
HEPATIC DISEASE
GENETIC DISORDER
INFECTIOUS DISEASE
BEHAVIORAL HEALTH
INFECTIOUS DISEASE
BEHAVIORAL HEALTH
SUBSTANCE ABUSE
DOMESTIC VIOLENCE
SUBSTANCE ABUSE
DOMESTIC VIOLENCE
TOBACCO USE
OTHER OBSTETRICAL COND
TOBACCO USE
OTHER OBSTETRICAL COND
OTHER MEDICAL CONDITIONS
OTHER MEDICAL CONDITIONS
HIV
HIV
If checked, please explain _______________________________________________________________________________
If checked, please explain _______________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
HCIC15081_303
1/1/14

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