Updated 1/3/20
CalOptima Pregnancy Notification Report (PNR)
FAX this form within 5 days of the 1st prenatal visit to CalOptima at 1-714-246-8677
MEMBER INFORMATION
Name: CIN: DOB:
Health Network: Phone Number(s):
Address: City: ZIP:
FIRST PRENATAL APPOINTMENT
Date of first prenatal appt: ___/___/____ Gravida (G): Para (P):
LMP: ___/___/___ EDC: ___/___/___ High Risk Pregnancy: Y / N
MEMBER CONDITIONS
Check the “at risk” box if member has a diagnosed condition. Provide comments, as needed.
CONDITION
AT RISK
INTERVENTION AND/OR ADDITIONAL COMMENTS
Age (<16 or >35)
<16: Parent/guardian aware of pregnancy: Y / N
____________________ _____________________
Name Relationship
Diabetes Circle one: Type 1 DM Type 2 DM GDM
Genetic condition(s)
History of preterm labor
(<37 weeks)
Hypertension
Late to Care/Insufficient
Care
Mental health disorder
Multiple gestation
Substance abuse
Use: Current User History of use
Substance: Alcohol Illicit Drugs Tobacco Other:
Other high-risk conditions
PROVIDER INFORMATION
Provider: Phone:
Office Contact Name: CPSP Certified: YES / NO
Stamp: PERINATAL SUPPORT SERVICES
Circle how services will be offered to the member
CPSP provided at
provider office
CalOptima to
coordinate CPSP
services
Member requests
NO contact
