Get the free Prematurity Prevention Program FAX REFERRAL FORM - depts washington

This form is used for referring patients to the Prematurity Prevention Program at the University of Washington Medical Center for evaluation and management of risk factors associated with preterm

How to fill out prematurity prevention program fax

How to fill out Prematurity Prevention Program FAX REFERRAL FORM

1. Obtain the Prematurity Prevention Program FAX REFERRAL FORM from your healthcare provider's office or the official program website.
2. Fill in the patient's personal information, including their full name, date of birth, and contact details.
3. Provide relevant medical history, including any previous pregnancies, complications, or health issues related to prematurity.
4. Complete the risk factor assessment section by checking any applicable boxes for lifestyle factors, medical conditions, or family history.
5. Include the name and contact information of the referring healthcare provider.
6. Sign and date the form where indicated, confirming that all information provided is accurate.
7. Fax the completed form to the designated number for the Prematurity Prevention Program.
8. Confirm receipt with the program by following up via phone or email, if necessary.

Who needs Prematurity Prevention Program FAX REFERRAL FORM?

1. Pregnant individuals at risk of preterm labor or delivery.
2. Women with a history of having a preterm birth in previous pregnancies.
3. Individuals with medical conditions that may contribute to prematurity, such as diabetes or hypertension.
4. Those with lifestyle risk factors, including smoking or substance use during pregnancy.

For pdfFiller’s FAQs

What is Prematurity Prevention Program FAX REFERRAL FORM?

The Prematurity Prevention Program FAX REFERRAL FORM is a document used to refer patients to programs aimed at preventing premature births and providing necessary support and resources.

Who is required to file Prematurity Prevention Program FAX REFERRAL FORM?

Healthcare providers, including obstetricians, midwives, and other medical professionals involved in prenatal care, are required to file the Prematurity Prevention Program FAX REFERRAL FORM when identifying at-risk patients.

How to fill out Prematurity Prevention Program FAX REFERRAL FORM?

To fill out the Prematurity Prevention Program FAX REFERRAL FORM, you need to provide the patient's information, including their medical history, risk factors for prematurity, and details about the care needed. Follow the instructions provided on the form carefully.

What is the purpose of Prematurity Prevention Program FAX REFERRAL FORM?

The purpose of the Prematurity Prevention Program FAX REFERRAL FORM is to ensure that at-risk patients receive timely referrals to programs and services that can help reduce the chances of premature birth.

What information must be reported on Prematurity Prevention Program FAX REFERRAL FORM?

The information that must be reported includes patient demographics, medical history, identified risk factors for prematurity, and the specific services or interventions being requested to prevent premature birth.