Select health pregnancy 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Provider Information section. Enter the provider's name, Tax ID number, address, phone, and fax number.
3. Next, move to the Member Information section. Input the member's name, Medicaid ID number, address, email, date of birth, phone number, and preferred language.
4. In the Tobacco Use section, indicate usage during pre-pregnancy and each trimester. Specify the average number of cigarettes smoked per day; if none, enter 0.
5. Complete the Pregnancy Information & History section by providing details about prenatal visits, abortion history, and any complications from previous pregnancies.
6. Fill out Active Mental Health Conditions and Social, Economic and Lifestyle Issues sections as applicable.
7. Finally, review all entries for accuracy before saving or submitting your form through our platform.

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