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 private.

Mother's Medicaid ID *

Mother's First Name (as it appears on your Medicaid ID card):

Mother's Last Name (as it appears on your Medicaid ID card):

Mother's Birth Date MM/DD/YYYY: *

Mother's Mailing Address: *

City: *

State: *

ZIP Code: *

Phone Number: *

Email Address: *

Confirm Email Address: *

Mother's OB Provider's Name: *

Would you like to receive texts about pregnancy/newborn care? * Yes No

Have you had an inpatient stay this pregnancy? Yes No

2. Do you have any chronic conditions such as high blood pressure, diabetes, asthma, or sickle cell disease during or before pregnancy? Yes No

3. Do you have a history of or currently taking progesterone, have preterm labor, or a short cervix? Yes No

Cribs and Car Seats from Meridian

If you are pregnant or trying to get pregnant, you may be eligible for Meridian’s Cribs and Car Seats program. All Meridian members who are pregnant or had a baby March 1st, 2024 or later are eligible for a FREE safety endorsed convertible car seat and Pack n’ Play. The Pack n’ Play can be used as a crib and includes a bassinet for safe sleep. To obtain your free crib and car seat, you or your doctor can fill out the Notice of Pregnancy form or call us for help.

Cribs and Car Seats from Meridian Flyer (PDF)

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: 10/10/2024