Pre-Notification Submission Form - Maternity

Congratulations on your pregnancy! We are excited to walk with you on this journey towards the birth of your child. The first step you’ll need to complete is submitting your Maternity Pre-Notification Form. This can be done by either yourself or your provider.

You or your provider can use this link to our online Pre-Notification Submission Form: Pre-Notification Submission Form

This form is easy to fill out and can be done by either you or your provider. Please also be sure to download the Statement of Conception form which is required for all Maternity Pre-Notifications. This form can be found here and is also linked in the Pre-Notification Submission Form.

As a reference here is all the information that is required to submit your Maternity Pre-Notification;

1. Member Name
2. Member Email Address
3. Membership ID Number
4. Provider Name
5. NPI Number
6. Provider Address
7. Provider Phone Number
8. Provider Fax Number
9. Facility Name
10. Facility Phone Number
11. Facility Fax Number
12. Date of ServiceClinical Notes
13. *LMP (If Maternity Pre-Notifcation)
14. *EDD (If Maternity Pre-Notification)