Delivery Notication
Fax completed form to Care Management at 682-885-8402
Delivery Facility: __________________________ Facility Phone: _________________________
Facility Contact: ___________________________ Facility Fax: ___________________________
OB Name: ________________________________ OB Phone: ____________________________
Member Name: ____________________________ DOB: _________________________________
Member ID: _______________________________ Member Phone: ________________________
Other Health Insurance?: ❏ Yes ❏ No If yes, insurance name: __________________
Admit Date: ____________________________
Delivery Date: __________________________
Delivery Type: ❏ SVD ❏C/S
Baby A: ❏ M ❏ F Birth Weight: ___________________________
Baby B: ❏ M ❏ F Birth Weight: ___________________________
Complications/Comments: _________________________________________________________________
________________________________________________________________________________________
Care Management Response
Reference Number ___________________________________ Date __________________
DELNOT120310
RevDec19