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NOTIFICATION OF PREGNANCY AND RISK SCREENING

The purpose of this form is to collect information relevant to clinical and social risk during pregnancy, to initiate contact with participants to offer prenatal case management services and supports, and to update the participant's MO HealthNet benefit category. Health plan members will be contacted by their respective plan upon receiving this information. For MO HealthNet (traditional Medicaid) participants, the medical care provider should inform pregnant women of available prenatal case management benefits, and a referral should be made to a MO HealthNet participating prenatal case management provider. For a list of prenatal case management providers, see: https://mymohealthportal.com/provider-search/.

A pdf of this form may be downloaded here.

 

Provider Information
Participant Information
Participant Information Continued

Choose all that apply: (Optional)

Race/Ethnicity

Clinical History

Previous pregnancy outcomes that may elevate risk:

Clinical History Continued
Social Risk Factors
Social Risk Factors Continued
Demographic / Access
Clinical History Calculations
Social Determinants of Health

 

This Notification of Pregnancy has been recorded.  Your patient’s initial risk level is considered {RiskScore}.  Your patient will be contacted by her managed care health plan or directly by MO HealthNet to offer pregnancy resources.  For higher-risk members unable to be reached, you may be contacted by email or phone to assist.

 

You may register your clinical teams as authorized users of the health plans’ Provider Portals to easily view health plan actions related to your patients who are health plan members, ensuring that follow-up communications such as sharing of Care Plans are viewable by the correct personnel. There may be options to subscribe to notifications, depending on the health plan.

 

Thank you for partnering with us to support Healthy Moms, Healthy Babies.

 

FormID: {formuniqueid}.

 

<--  Please print this document to PDF and save in your patient’s medical record.