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Division of Medical
Assistance Programs

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:

Phone number:
Medicaid ID Number:

(Last, First, MI)

(DOB)

(from DMAP Medical ID)

Father of the Unborn’s Full Legal Name and DOB:
(DOB)

Patient Signature:

Date:
To be completed by the provider:
Estimated Due Date:(Month)

(Year)

Provider Name:(Print)

Signature:
Date:

(Provider, office staff or managed care representative)

Phone:

Fax:

Fax to (503) 373-0868
or mail the form to:
OHP
PO Box 145