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Notification of Pregnancy

Short Version

Completion of this form will allow us to support you to the best of our ability to ensure you have a healthy and successful pregnancy. This form is also used to tell Meridian your interest in the Safe Sleep Crib Program

Once this form is completed, a Meridian representative will call you to complete a full pregnancy and health risk assessment, share information about community resources and your pregnancy benefits, and confirm delivery details for the Pack N’ Play crib. This call must be completed to receive the crib. This form is private. 

Would you like to receive texts about pregnancy/newborn care? required *
Have you had an inpatient stay this pregnancy?
2. Do you have any chronic conditions such as high blood pressure, diabetes, asthma, or sickle cell disease during or before pregnancy?
3. Do you have a history of or currently taking progesterone, have preterm labor, or a short cervix?
What is your housing situation today?
In the past two months, did you or others you live with eat smaller meals or skip meals because you did not have enough money for food?
In the past 12 months, has a lack of reliable transportation kept you from going to medical appointments, meetings, work, or doing things needed for daily living?
In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home?
Do you feel unsafe in your daily life?
Are you unemployed or without regular income?
How often do you feel lonely?
Which of the following would you like to get help with at this time? Select ALL that apply.

 

DISCLAIMER:

Please be aware that email communication, including attachments, may not be secure and could be intercepted, corrupted, lost, destroyed, delayed, incomplete, or contain viruses. Therefore, the integrity of email transmission cannot be guaranteed.

By communicating with us via email, you acknowledge and accept these risks. While we take reasonable precautions to ensure the security and confidentiality of email transmissions, we cannot guarantee the security of any information transmitted via email.

It is important to refrain from including sensitive or confidential information in email messages unless encrypted or otherwise protected. If you have concerns about the security of your communication or need to transmit sensitive information, please consider using alternative secure methods of communication.

We disclaim any liability for damages arising from the use of email communication, including but not limited to any direct, indirect, incidental, consequential, or punitive damages, whether foreseeable or not, resulting from the transmission or reception of email messages.

If you have any questions or concerns about the security of email communication, please call Member Services at 1-888-437-0606 (TTY 711).

 

Last Updated: 12/20/2024