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UPS Marquette | Specialty Clinic Medical Office Building 850 W Ba raga Ave. Marquette, MI 49855 P: 906.449.4880 | F: 906.449.1815MATERNALFETAL MEDICINE REFERRAL Formulas fax this request to the Specialty

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How to fill out maternal-fetal medicine referral form

1. Obtain a maternal-fetal medicine referral form from your healthcare provider.
2. Fill out the patient's personal information, including name, date of birth, and contact information.
3. Provide details about the referring physician, including name, contact information, and reason for referral.
4. Include any relevant medical history or previous prenatal care information.
5. List any current pregnancy complications or concerns that warrant a maternal-fetal medicine consultation.
6. Make sure to sign and date the referral form before submitting it to the maternal-fetal medicine specialist.

Who needs maternal-fetal medicine referral form?

1. Pregnant women who are experiencing complications during pregnancy such as high blood pressure, gestational diabetes, or a history of pregnancy loss may need a maternal-fetal medicine referral form.
2. Women with preexisting medical conditions such as diabetes, hypertension, or autoimmune disorders may also benefit from a maternal-fetal medicine consultation.

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What is maternal-fetal medicine referral form?

The maternal-fetal medicine referral form is a document used to facilitate the referral of patients from general obstetrician-gynecologists to specialists in maternal-fetal medicine for the management of high-risk pregnancies.

Who is required to file maternal-fetal medicine referral form?

Obstetricians, gynecologists, and other healthcare providers who are managing pregnancies classified as high-risk are required to file the maternal-fetal medicine referral form.

How to fill out maternal-fetal medicine referral form?

To fill out the maternal-fetal medicine referral form, the referring provider must complete sections detailing the patient's medical history, risk factors, and any relevant diagnostic information, ensuring all required fields are accurately filled out.

What is the purpose of maternal-fetal medicine referral form?

The purpose of the maternal-fetal medicine referral form is to ensure that patients with high-risk pregnancies receive appropriate specialist care and to provide essential medical information for continuity of care.

What information must be reported on maternal-fetal medicine referral form?

The information that must be reported includes the patient's personal details, medical history, specific reasons for the referral, and any relevant lab or imaging results.