Fillable High Risk Pregnancy Notication (Cook Children's Health Plan)

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High Risk Pregnancy Notication (Cook Children's Health Plan)

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High Risk Pregnancy Notication
Complete this form, print and fax to 682-885-8402 at the time of pregnancy diagnosis.
Use the CCHP Service Authorization Request Form for authorization if your pregnant patient
requires a hospital or observation stay without delivery, or an out of network referral.
Baby Steps Program 888-243-3312; Fax 682-885-8402
Provider Information
OB Name: ________________________________________________________________________________
OB Phone: ______________________________________OB Fax: _________________________________
OB Ofce Contact: ______________________________ Perinatologist Ofce Contact: ________________
Perinatologist: __________________________________ Perinatologist Phone/Fax: ___________________
Expected Delivery Facility: __________________________________________________________________
Member Information
Member Name: ___________________________________ DOB: ____________________________________
ID: _____________________________________________Member Phone: ___________________________
EDC (Due Date) _______________________LMP: ________________________G: ________ P: ________
Other Health Insurance?: ❏ Yes ❏ No If yes, Insurance Name: _______________________________
Risk Factors/Problems: ____________________________________________________________________
_________________________________________________________________________________________
Medications: ❏ NONE ❏ Yes (If Yes, list): _____________________________________________________
_________________________________________________________________________________________
Rev10/2010sf
RevOct-19
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High Risk Pregnancy Notication (Cook Children's Health Plan)

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Completed 7 May 2021

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