Get the free High-Risk Pregnancy Referral Form. 26165-High-Risk Pregnancy Referral Form.pdf

High-rise Pregnancy Referral Former provider use only. Please complete this form for all Health Net members with high risk pregnancies within 7 days of identification. Fax form to secure fax line

How to fill out high-risk pregnancy referral form

How to fill out high-risk pregnancy referral form

1. Obtain the high-risk pregnancy referral form from the appropriate healthcare provider or facility.
2. Fill out all patient information accurately, including name, contact information, and relevant medical history.
3. Provide details about the pregnancy, including gestational age, any complications or risk factors, and current treatment options.
4. Include information about any previous pregnancies and their outcomes, as well as any genetic or family history that may be important.
5. Sign and date the form, ensuring that all information provided is complete and accurate.
6. Submit the completed form to the designated healthcare provider or facility for review and further action.

Who needs high-risk pregnancy referral form?

1. Pregnant individuals who have been identified as having a high-risk pregnancy by their healthcare provider.
2. Patients with preexisting medical conditions or other factors that may increase the risk of complications during pregnancy.

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What is high-risk pregnancy referral form?

The high-risk pregnancy referral form is a document used to refer pregnant women who are at high risk for complications during pregnancy.

Who is required to file high-risk pregnancy referral form?

Healthcare providers, such as doctors or midwives, are required to file the high-risk pregnancy referral form for pregnant women who are at high risk.

How to fill out high-risk pregnancy referral form?

The high-risk pregnancy referral form can be filled out by providing the pregnant woman's personal information, medical history, current pregnancy details, and any risk factors.

What is the purpose of high-risk pregnancy referral form?

The purpose of the high-risk pregnancy referral form is to ensure that pregnant women who are at high risk for complications receive the necessary care and monitoring.

What information must be reported on high-risk pregnancy referral form?

The high-risk pregnancy referral form must include the pregnant woman's personal information, medical history, current pregnancy details, any risk factors, and the reason for the referral.