Member Notiﬁcation of Pregnancy
his form is confidential. If you have any problems or questions, please call
Absolute Total Care at 1-866-433-6041
(TTY: 711). This form is also available
online at absolutetotalcare.com.
*Are You Pregnant?
Yes No * If you are pregnant, please continue to answer all the questions.
Return the form in the envelope provided. When your answers are received, a gift will be mailed to you!
We may call you if we ﬁnd that you are at risk for problems with your pregnancy.
*Medicaid ID #: Today’s Date MMDDYYYY:
Your First Name:
Your Last Name:
*Your Birth Date MMDDYYYY:
City: State: Zip Code:
Home Phone: Cell Phone:
Would you like to receive text messages about pregnancy and newborn care? Yes No
If you do not have an unlimited texting plan, message and data rates may apply. Text STOP to unsubscribe.
Please note, texting is not secure and may be seen by others.
*Your OB Provider’s Name:
*Your Due Date MMDDYYYY:
Primary insurance (for mom or baby) other than Medicaid? Yes No
Race/Ethnicity (select all that apply): White Black/African American Hispanic/Latina
American Indian/Native American Asian Hawaiian/Paciﬁc Islander
Other If other ethnicity, please specify:
Preferred Language (if other than English):
Planning to breastfeed? Yes No If no, what is the reason?
Pediatrician chosen? Yes No Pediatrician Name:
Number of Full Term Deliveries: Number of Miscarriages:
Number of Preterm Deliveries: Number of Stillbirths:
Height (Feet, Inches):
*Do you have any of the following? Yes No If yes, mark all that apply.
Your Medical History
Previous preterm delivery (<37 weeks or a delivery more than three weeks early)? Yes No
Recent delivery within past 12 months? Yes No Was delivery within past 6 months? Yes No
Previous C-Section? Yes No Diabetes (Prior to Pregnancy)? Yes No
© 2020 Start Smart for Your Baby. All rights reserved.
Rev. 12 19 2019