Obstetrical Notification Form Physician Certification

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Dear Physician: We are requesting that you please complete this Obstetrical Notification form for the obstetrical services of this patient. Please mail or fax this information to the address indicated above or via fax 305-384-7059. This information must be received two days prior to the patient’s next prenatal visit appointment (weekends and holidays excluded).

Patient’s Name:

Date of Birth:

Estimated Date of Conception:

Estimated Date of Delivery:

Medical history, social history, habits or conditions that may affect this pregnancy

Are there any conditions that may put the patient at risk of Pre-Term Labor?

Initial Physical Exam:

Height:

Width:

BP:

Thyroid:

Signs of Underlying Heart Disease:

Yes

Is normal delivery being planned at this time?

Yes

Please see the attached Routine Pre-Natal Care Guidelines expected for this patient, for an outline of the routine prenatal visits, labs and documentation required during pregnancy period. All guidelines are based on the practice and recommendations for routine prenatal care as stated by the American College of Obstetrics and Gynecology ACOG, and the American Academy of Family Physicians AAFP.

Kindly refer patient for any diagnostic laboratory, ultrasound or for the purposes of delivery to a participating provider. For information on participating providers please call 305-760-8739.

All bills will be processed following CPT code guidelines and Correct Coding Initiative rules. Please make sure to use current CPT codes and ICD10-CM for claims in order to avoid delays in payment. For all billing questions, please call 305-760-8739.

Signature of Physician Completing this form:

Degree:

Date:

Printed Name:

Phone: