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- Begin by entering the patient’s full name and birthdate in the designated fields. Ensure accuracy as this information is crucial for identification.
- Input the patient’s due date, which is essential for determining eligibility for the W-2 ARP placement.
- Indicate whether the patient has a high-risk pregnancy by selecting 'Yes' or 'No'. If 'Yes', provide details about the cause of the high-risk status in the comments section.
- Fill in the start date for when the patient became unable to work due to their high-risk pregnancy, if applicable.
- Complete the physician’s information, including specialty area, NPI, office address, and contact details. Ensure that all fields are filled out legibly.
- Finally, have the physician sign and date the form before submitting it back to the agency listed at the top.
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