The Health Plan of the Upper Ohio Valley > Provider Services > Provider Forms

Please complete the following form:

* Required Fields

Physician/RN Comments:

Date of Birth
Member Name*
Member ID (must be 9 characters)*
EDC
Address
City
Zip Code
Phone Number*
Provider Phone Number
Obstetrician*
Low Birth Weight
Email Address
Did members last pregnancy result in C section?	Yes
. . . In a miscarriage?	Yes
Did baby weigh less than 5lb. 8oz.?	Yes
Was baby born more than 3 weeks early?	Yes
Did baby stay in hospital after mother was discharged?	Yes
Preterm & Medical Risk Factors (check each factor that applies)
Current episode of preterm labor	Yes
Previous Preterm labor	Yes
Multiple gestation this pregnancy	Yes
Known history of cocaine, marijuana, or street drugs this pregnancy	Yes
Use of tobacco products since last menstrual period	Yes
Use of any beer, wine, wine coolers, or liquor since last menstrual period	Yes
Incompetent cervix with cerclage	Yes
Uterine abnormality	Yes
Chronic hypertension	Yes
Diabetes mellitus at conception, insulin dependent	Yes
Diabetes mellitus at conception, non-insulin dependent	Yes
Infertility Meds/Assisted Reproductive Technology to achieve pregnancy	Yes
Other cause for medical concern (explain in comments)	Yes