Fillable PRENATAL CARE PROVIDER REPORT FORM PERINATAL HEPATITIS B (Kansas Department of Health and Environment)

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PRENATAL CARE PROVIDER REPORT FORM PERINATAL HEPATITIS B (Kansas Department of Health and Environment)

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PRENATAL CARE PROVIDER REPORT FORM
PERINATAL HEPATITIS B PREVENTION
Please complete the form with as much information as possible and FAX to the Perinatal Hepatitis B
Prevention Program at 1-877-427-7318.
PROVIDER’S NAME____________________________PROVIDER’S PHONE NUMBER (____)___________
ADDRESS __________________________________________________________________________________
TODAY’S DATE _____ / _____ / _____
MOTHER’S INFORMATION
Last Name:
First Name:
Date of Birth: / /
HBsAg positive test date: / /
Address:
City:
Zip Code:
Contact Phone #: ( )
Alternative Phone #: ( )
Anticipated Delivery Hospital:
Estimated Delivery Date: / /
Anticipated Pediatrician Name:
Anticipated Pediatrician Phone #: ( )
Insurance:
Medicaid
Private Insurance
Uninsured
Other (please specify) _______________
Race: (check all that apply)
African American or Black Caucasian or White
American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander
Asian
Race, not otherwise specified
Hispanic
Ethnicity:
Yes
No
For questions or more information please call (785) 368-8208.
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PRENATAL CARE PROVIDER REPORT FORM PERINATAL HEPATITIS B (Kansas Department of Health and Environment)

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Completed 14 August 2020

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