NEWBORN Notification Form - UHCCommunityPlan 2025

1. Click ‘Get Form’ to open the NEWBORN Notification Form in the editor.
2. Begin by entering today’s date at the top of the form. This is essential for tracking purposes.
3. Fill in the attention line and provide your phone number, along with your name as the requester.
4. In the Member Information section, input the mother's name, date of birth, ID number, discharge date, phone number, and address details including city, state, and zip code.
5. Complete the Newborn section by entering details such as admitting physician's name, gender, date of birth, time of birth, weight, Apgar scores, gestational age (GA), delivery method (vaginal or C-section), and health status (sick or well) along with any diagnosis.
6. If applicable, fill in information regarding whether the mother was sterilized and provide the date if yes.
7. For auto-assigned babies, complete their last name and AHCCCS representative number.
8. Finally, ensure that APIPA staff completes their section with newborn ID numbers and authorization numbers before submitting.

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