PeerPlace Public Perinatal Portal

REQUEST FOR SERVICES

Please complete as much information as possible so we can make the best possible referrals for you.

Required fields (marked with *) must be completed before submitting or an error will result and all fields will be reset. Use only numbers, no commas, in Annual Income; all date fields must be formatted as MM/DD/YYYY.

Requester Information (for requests on behalf of someone else)

Requester Name:

Requester Phone:

Requester Phone - -

Requester Agency Name:

Requester Email Address:

Requester Phone Ext:

Information on person needing services

First Name of person needing services *:

Last Name of person needing services *:

Preferred Method of Contact *:

Address 1:

Address 2:

City:

Other City:

State:

Zipcode:

Phone(Home):

Phone(Home) - -

Phone(Mobile):

Phone(Mobile) - -

Phone(Work):

Phone(Work) - -

Work Ext:

Email Address:

Who told you about the program:

Issues/Needs:

Best Time to Contact:

Pets in home (list):

Date of Birth:

Age:

Annual Income:

# in Household:

Health Ins Provider:

Homeless:

Homeless: Select One No Yes

Pregnant:

Are you planning a pregnancy in the next 12 months:

Would you like to learn more about planning for a future pregnancy?:

Would you like to learn more about planning for a future pregnancy?: Select One No Yes

Would you like to learn more about your birth control options?:

If pregnant, Due Date:

# pregnancies including this one:

# previous live births:

Youngest Child`s Age:

Date of birth of youngest child:

Have you delivered a baby before the due date in the past:

Have you delivered a baby before the due date in the past: Select One No Yes

Have you had a dental cleaning within the last six months:

Have you had a dental cleaning within the last six months: Select One No Yes

Are there any problems in your mouth? (Bleeding gums, toothaches, loose tooth, etc.):

Are there any problems in your mouth? (Bleeding gums, toothaches, loose tooth, etc.): Select One No Yes

Comments:

Additional Information

Height (inches):

Weight (pounds):

Due Date Determined By:

Date of Last Period:

Estimated date became pregnant:

If pregnant, have you begun care for your pregnancy:

If pregnant, have you begun care for your pregnancy: Select One No Yes

Date of First Pregnancy Care Visit:

Billing Prenatal Care Provider:

Do you have a family planning provider:

Do you have a family planning provider: Select One No Yes

Provider Name / Physician:

Billing Group Number:

Provider Phone:

Provider Phone - -

Hospital:

Diagnosis:

Contract #/Member ID #:

Risk Factors

Social Risks:

Pregnancy Risks - Current Conditions:

Pregnancy Risks - Prior Pregnancy:

Medical Risks - Current Conditions:

Medical Risks - On Medications:

Confidential Risks - Current Conditions:

Confidential Risks - History and Medications:

Consents

I attest that I am giving consent for myself or have obtained consent from the client to share client contact information with the Information and Assistance *:

I attest that I am giving consent for myself or have obtained consent from the client to share social and medical risk information with the Information and Assistance *:

I attest that I am giving consent for myself or have obtained it from the client to share confidential health and other risk information that may include abuse, mental health, STD and HIV/AIDS-related information and treatment *:

The below disclosures will be part of the referral submissions to all receiving providers.This is to protect patient privacy and information.Each disclosure made with the patient's written consent must be accompanied by the following written statements

State of New York

OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES

PROHIBITION ON REDISCLOSURE OF INFORMATION CONCERNING

SUBSTANCE ABUSE PATIENT

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2 and HIPAA). The federal rules prohibit you from making further disclosure of this information unless further disclosure

is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and/or HIPAA. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

For more information please visit, the link:

Information

TRS-1 (5/03) - For alcohol and substance abuse

State of New York

PROHIBITION ON REDISCLOSURE OF HIV RELATED INFORMATION

HIV related information may not be disclosed unless the client signs an approved HIV specific release form. Whenever HIV-related information is disclosed it must be accompanied by the following or similar statement:

"This information has been disclosed to you from confidential records which are protected by state law.

State law prohibits you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.

Any unauthorized further disclosure in violation of state law may result in a fine or jail sentence or both. A general authorization for the release of medical or other information is NOT sufficient for further disclosure."

For more information please visit, the link:

Information

Healthy Start Additional Information

Type of Referral:

If you are filling out this form for someone else, please enter your name/referring agency:

If agency referral is the client aware?:

Phone # of person making request:

Phone # of person making request - -

Information for Person Needing Services

Gender:

Gender: Select One Unspecified Male Female

Medicaid No.:

Contact Information for Person Needing Services (i.e. provide Parent/Guardian information for Infant/Children)

Parent/Guardian First Name:

Parent/Guardian Last Name:

Parent/Guardian DOB:

Parent/Guardian Relationship to Infant/Child:

Additional Infant Questions - Please complete as much information as possible so we can make the best possible referrals for you.

Baby`s Birth Weight:

Baby`s Discharge Weight:

Weeks Gestation:

Type of Feeding:

Any complications?:

Any complications?: Select One Yes No

Doctor/Pediatrician Name:

Doctor Address 1:

Doctor Address 2:

Doctor City:

Doctor State:

Doctor Zipcode:

Doctor Phone:

Doctor Phone - -

Additional Child Questions - Please complete as much information as possible so we can make the best possible referrals for you.

Child Weight:

Child Diet:

Medical Conditions:

Doctor/Pediatrician Name:

Doctor Address 1:

Doctor Address 2:

Doctor City:

Doctor State:

Doctor Zipcode:

Doctor Phone:

Doctor Phone - -

Additional Postpartum Questions - Please complete as much information as possible so we can make the best possible referrals for you.

Delivery Date:

Type of Delivery:

# Previous Pregnancies:

# Living Children:

Doctor/Pediatrician Name:

Doctor Address 1:

Doctor Address 2:

Doctor City:

Doctor State:

Doctor Zipcode:

Doctor Phone:

Doctor Phone - -

Infant/Child First Name:

Infant/Child Last Name:

Infant/Child DOB:

Gender:

Gender: Select One Unspecified Male Female

Doctor/Pediatrician Name:

Process Request:

Baby care
Breastfeeding support
Child development concerns
CHW
Counseling Resources
Doula Support
Elevated lead
Hepatitis B
Home Visiting
Needs Assistance
Nurse Family Partnership
Nursing
Parenting up to age 2
PCAP
Post Partum
Pre-K E.I
Pregnant and need assistance
Pregnant and need insurance/doctor
Social Work
Website Screening and Referral
WIC