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Pregnancy Assessment Form Name Address City State Zip Phone Date of Birth Member ID Current Weight Obstetric Provider Provider Phone Fax EDC G P Date of First Prenatal Visit Delivering Hospital Referral Number This section should be completed by the member and reviewed by the health care provider. X Risk Factors Comments Previous preterm delivery Number of preterm deliveries 37 weeks gestation Gestational age at delivery 17P Candidate Requested start date Multiple gestation this pregnancy Twins triplets etc* High blood pressure Chronic or history with previous pregnancy Diabetes Type 1 Type 2 Previous gestational diabetes Coagulation disorder Use of or Reason History of incompetent cervix Cerclage Current tobacco use Quit date Current alcohol use Current drug use Domestic violence or other psychosocial issue Best time and number for contact Genitourinary complications History of kidney stones or urinary tract infection Second delivery in less than one year Date of delivery Younger than 18 or older than 35 Mental health issues Physical/stressful employment Describe History of seizure disorder Fibroids or uterine abnormality Medical history Current medications Member signature Date Provider signature Please return this form to the Precertification/Referral Authorization department by mailing it to the following address or faxing it to 717 541-5764 or 888 247-4791. HealthAmerica Attn* Utilization Department/Preauthorization Request 3721 TecPort Drive Harrisburg PA 17106-7103 If you have questions please feel free to call us at 1-800-755-1135. X Risk Factors Comments Previous preterm delivery Number of preterm deliveries 37 weeks gestation Gestational age at delivery 17P Candidate Requested start date Multiple gestation this pregnancy Twins triplets etc* High blood pressure Chronic or history with previous pregnancy Diabetes Type 1 Type 2 Previous gestational diabetes Coagulation disorder Use of or Reason History of incompetent cervix Cerclage Current tobacco use Quit date Current alcohol use Current drug use Domestic violence or other psychosocial issue Best time and number for contact Genitourinary complications History of kidney stones or urinary tract infection Second delivery in less than one year Date of delivery Younger than 18 or older than 35 Mental health issues Physical/stressful employment Describe History of seizure disorder Fibroids or uterine abnormality Medical history Current medications Member signature Date Provider signature Please return this form to the Precertification/Referral Authorization department by mailing it to the following address or faxing it to 717 541-5764 or 888 247-4791. HealthAmerica Attn* Utilization Department/Preauthorization Request 3721 TecPort Drive Harrisburg PA 17106-7103 If you have questions please feel free to call us at 1-800-755-1135.

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