Get the free Perinatal Referral Form - mercycareplan.com

PERINATAL REFERRAL FORM Please fax to (602) 4317552 or OB faxes aetna.com Doctors Name: Provider ID #: Doctors Phone #: Doctors Fax #: Office Contact Person: Extension #: Members Name: Members ID

How to fill out perinatal referral form

How to fill out perinatal referral form

1. To fill out the perinatal referral form, follow these steps:
2. Start by providing your personal information, including your name, date of birth, contact information, and any previous medical history related to pregnancy.
3. Next, specify the reason for the referral, such as seeking preconception counseling, prenatal care, or a high-risk pregnancy consultation.
4. Indicate the healthcare provider or facility you wish to be referred to, providing their contact information if available.
5. Include any relevant details or concerns you have regarding your pregnancy or medical condition that may assist the healthcare provider in understanding your needs.
6. Review the completed form for accuracy and completeness before submitting it to the appropriate authority or healthcare provider.
7. If required, ensure that you have all supporting documents or test results ready to be attached to the referral form.
8. Finally, submit the filled-out perinatal referral form to the designated recipient or follow the specific instructions provided by your healthcare provider.

Who needs perinatal referral form?

1. Perinatal referral forms are typically needed by pregnant individuals or those planning for pregnancy who require specialized medical care during the perinatal period.
2. This may include individuals with high-risk pregnancies, those seeking prenatal care or genetic counseling, individuals with specific medical conditions that may affect pregnancy, or those referred by their primary healthcare provider for consultation with a perinatal specialist.
3. These referral forms are essential for ensuring effective communication and coordination of care between healthcare providers and ensuring that individuals receive appropriate and timely perinatal care.

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What is perinatal referral form?

The perinatal referral form is a document used to refer a pregnant individual to specialized medical care during pregnancy, labor, and delivery.

Who is required to file perinatal referral form?

Healthcare providers, including obstetricians, midwives, and nurses, are required to file the perinatal referral form for their patients.

How to fill out perinatal referral form?

The perinatal referral form must be filled out with the patient's medical history, current pregnancy details, and reason for referral to a specialist. It should be submitted to the appropriate healthcare facility.

What is the purpose of perinatal referral form?

The purpose of the perinatal referral form is to ensure that pregnant individuals receive necessary specialized care and support during pregnancy, labor, and delivery.

What information must be reported on perinatal referral form?

The perinatal referral form must include the patient's medical history, current pregnancy information, reason for referral, and any relevant test results or complications.