Maternity Care Management Notification Form - Providers ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Member Information. Fill in the Member Name, Member ID, Date of Birth, Estimated Date of Delivery, and select the Trimester of Pregnancy. Ensure accuracy as this information is crucial for care management.
3. Next, provide the Member Address and Phone Numbers. This section helps maintain communication with the member throughout their care journey.
4. Proceed to fill out Provider Information. Enter your name, address, practice phone number, fax number, and Provider ID. This identifies you as the referring provider.
5. In the Provider Reason for Referral section, check all applicable conditions that pertain to the current pregnancy. This helps in assessing the member's needs effectively.
6. Finally, sign and date the form at the bottom to validate your referral.

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