Division of Medical
Oregon Health Plan Pregnancy Notification
It is important to identify a pregnant OHP/Medicaid client as early
in her pregnancy as possible.
This form only needs to be submitted once or if there is a change.
Has the family completed an OHP application?
Yes__ Date:_______ No__
To report a pregnancy for an OHP/Medicaid patient, please complete
the information listed below.
- Complete All Fields - Print Legibly This form will not be processed if it is illegible or incomplete.
To be completed by patient:
Print Legal Name and DOB:
Medicaid ID Number:
(Last, First, MI)
(from DMAP Medical ID)
Father of the Unborn’s Full Legal Name and DOB:
To be completed by the provider:
Estimated Due Date:(Month)
(Provider, office staff or managed care representative)
Fax to (503) 373-0868
or mail the form to:
PO Box 145