High-Risk Pregnancy Notification Form Miami-Dade County Health Department Perinatal Please send confidential fax to: 305-470-5533 Required Reporting Information (per Florida Statute: 64D-3-2026

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High-Risk Pregnancy Notification Form Miami-Dade County Health Department Perinatal Please send confidential fax to: 305-470-5533 Required Reporting Information (per Florida Statute: 64D-3 Preview on Page 1

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  1. Click ‘Get Form’ to open it in our editor.
  2. Begin by filling in the 'Today’s Date' field with the current date.
  3. Enter the 'Facility Name' where the patient is being treated.
  4. Provide the 'Physician Name' responsible for the patient's care.
  5. Input the 'Office Chart ID/File #' for tracking purposes.
  6. Complete the 'Gravida/Para' section to indicate pregnancy history.
  7. Fill in the 'Estimated Delivery Date' based on medical assessments.
  8. Specify the 'Hospital Name' where delivery is planned.
  9. Indicate if medication was prescribed by checking 'Yes' or 'No'.
  10. If applicable, enter the 'Date Prescribed' for any medications.
  11. Note whether a referral to an Infectious Disease Specialist/Perinatologist was made.
  12. Fill in your details as the reporter, including your name and telephone number.
  13. Once completed, ensure all information is accurate before submitting. Place this form in the patient’s office chart and fax it to 305-470-5533 within two weeks of diagnosis.

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