Pregnancy Notification - Providers - Texas Children's Health Plan



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Pregnancy Notification Form

The online pregnancy notification form should be submitted after the initial prenatal visit to facilitate enrollment of pregnant members into Texas Children's Health Plan's STAR Babies Program and identify high risk members for Case Management. The form must be completed in its entirety for it to be accepted. Any questions regarding this form should be directed to Texas Children's Health Plan Provider Relations at 832-828-1008.

* Please note, completion of this form is for informational purposes only and is not an authorization of services. For authorization, contact TCHP Medical Management at 832-828-1004, Option 2 or 800-990-8247.

Physician information
Submitting physician:
Physician tax ID:
OB's name:
Office contact:
Office phone number: xxx-xxx-xxxx
Office fax number: xxx-xxx-xxxx
Delivery facility:
Member information
Member's name:
Member's ID number:
Date of birth: (mm/dd/yyyy)
Member phone number: xxx-xxx-xxxx
Member alternate phone number: xxx-xxx-xxxx
Street address:
Member's city:
Member's state:
Member's zip:
Clinical information
Gravida/Para/AB/living: (xx/xx/xx/xx)
Expected date of delivery: (mm/dd/yyyy)
Weeks gestation:
Did the member receive previous prenatal care?	Yes No
If yes, where?
Date of first prenatal visit: (mm/dd/yyyy)
Date of first office visit with this physician for this pregnancy: (mm/dd/yyyy)

Please list any risk factors:

Please list other comments or special information: