Delivery Notification Worksheet Form

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Delivery Notification Worksheet
Facility Information
Facility name 
 Call back # 
Facility contact person 
 Fax # 
Member Information
Member name 
 Medicaid ID # 
Admission date 
 Delivery date 
 D/C date 
Delivery Information
Name of delivering physician 
Type of delivery:  Vaginal
 VBAC
 C/S
 Repeat C/S
Gestational age:________________
EDC:________
 Single birth
 Multiple birth:
 Twins
 Triplets
 Other:______________________
Baby A name:______________________________ Sex:  Male
 Female
Weight (grams):___________
Well nursery:
 Yes
 No
If No:  NICU
 SCN
Baby A D/C date:_________________________
Transfer to facility: ___________________________ Clinical sent:
 Yes
 No
Baby A physician:_______________________
Baby A has been referred for Newborn Home Visit:  Yes
If Yes which agency:_______________________________
 No
Baby B name:_______________________________ Sex:  Male
 Female
Weight (grams):___________
Well nursery:
 Yes
 No
If No:  NICU
 SCN
Baby B D/C date:_________________________
Transfer to facility: ___________________________ Clinical sent:
 Yes
 No
Baby B physician:_______________________
Baby B has been referred for Newborn Home Visit:  Yes
If Yes which agency:_______________________________
 No
Baby C name:_______________________________ Sex:  Male
 Female
Weight (grams):___________
Well nursery:
 Yes
 No
If No:  NICU
 SCN
Baby C D/C date:_________________________
Transfer to facility: ___________________________ Clinical sent:
 Yes
 No
Baby C physician:_______________________
Baby C has been referred for Newborn Home Visit:  Yes
If Yes which agency:_______________________________
 No
This information may be called or faxed to the Maternal Child Department.
Phone: 1.888.559.1010
Fax: 1.866.533.5493
Select Health Bright Start | PO Box 40849 | Charleston, SC 29423 | Toll free: 1.888.559.1010 | Fax: 1.866.533.5493 |

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