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.
Request for Perinatal Services
Please complete as much information as possible so we can make the best possible referrals for you.
Requester Information (for requests on behalf of someone else)
Requester Phone  -  -
Information on person needing services
Phone(Home)  -  -
Phone(Mobile)  -  -
Phone(Work)  -  -
Homeless: Select One
Would you like to learn more about planning for a future pregnancy?: Select One
Have you delivered a baby before the due date in the past: Select One
Have you had a dental cleaning within the last six months: Select One
Are there any problems in your mouth? (Bleeding gums, toothaches, loose tooth, etc.): Select One
Additional Information
If pregnant, have you begun care for your pregnancy: Select One
Do you have a family planning provider: Select One
Provider Phone  -  -
Risk Factors
Social Risks: Select One or More
Pregnancy Risks - Current Conditions: Select One or More
Pregnancy Risks - Prior Pregnancy: Select One or More
Medical Risks - Current Conditions: Select One or More
Medical Risks - On Medications: Select One or More
Confidential Risks - Current Conditions: Select One or More
Confidential Risks - History and Medications: Select One or More
Consents
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.
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."
Information
Healthy Start Additional Information
Phone # of person making request  -  -
Information for Person Needing Services
Gender: Select One
Contact Information for Person Needing Services (i.e. provide Parent/Guardian information for Infant/Children)
Additional Infant Questions - Please complete as much information as possible so we can make the best possible referrals for you.
Any complications?: Select One
Doctor Phone  -  -
Additional Child Questions - Please complete as much information as possible so we can make the best possible referrals for you.
Doctor Phone  -  -
Additional Postpartum Questions - Please complete as much information as possible so we can make the best possible referrals for you.
Doctor Phone  -  -
Gender: Select One