horizonNJhealth.com

Self-Referral Form
Tell us About Yourself

Tell us About Your Pregnancy

Mom?s GEMS
(Getting Early Maternity Services)

Name: _________________________________________________ Today?s Date: _____________________

Horizon NJ Health ID #: _____________________________________ Date of Birth: _____________________

Address: ____________________________________________ City/State/Zip: _________________________

Phone Number: ______________________________ Other Phone: ___________________________________

Your Doctor?s Name: ________________________________________ Due Date: _______________________

Who will be the doctor for your baby after you deliver? _________________________________________________

Are you having financial problems (transportation, food)? ? Yes ? No
If ?Yes?, please explain ________________________________________________________________________

1. How many times have you been pregnant, including now? _______

2. Have you been diagnosed with preterm labor or a weak cervix during this pregnancy? ? Yes ? No
3. Are you having any other problems with your current pregnancy? ? Yes ? No
If ?Yes?, please explain ____________________________________________________________________

4. Have you had a baby that was born more than 3 weeks before your due date? ? Yes ? No
5. Have you ever been told you have high blood pressure? ? Yes ? No
6. Have you ever been told you have diabetes? ? Yes ? No
7. Do you have any problems with mental illness or depression? ? Yes ? No
8. Do you smoke? ? Yes ? No If so, how much ___________________________________

Do you drink alcohol? ? Yes ? No If so, how much ___________________________________
Do you take street drugs? ? Yes ? No If so, how much ___________________________________

9. Are you now or have you ever been a victim of physical or sexual abuse? ? Yes ? No
10. Are you planning on breast feeding? ? Yes ? No
11. Are you enrolled with WIC? ? Yes ? No
12. Please provide us with the best way to contact you: _______________________________________________

________________________________________________________________________________________

28105 (W0918)

Products and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey,
each an independent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by Horizon Blue
Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all of its companies.
? 2018 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

Comments/Request for Information: _____________________________________________________________

________________________________________________________________________________________

Please email your completed form to ExpectingMom@HorizonBlue.com.
Please fax your completed form to 1-609-583-3039.

If you have any questions, please contact Mom?s GEMS at 1-800-682-9090 (TTY 711).


Name:
Todays Date:
Horizon NJ Health ID:
Date of Birth:
Address:
CityStateZip:
Phone Number:
Other Phone:
Your Doctors Name:
Due Date:
Who will be the doctor for your baby after you deliver:
If Yes please explain:
How many times have you been pregnant including now:
If Yes please explain_2:
If so how much:
If so how much_2:
If so how much_3:
12 Please provide us with the best way to contact you 1:
12 Please provide us with the best way to contact you 2:
CommentsRequest for Information 1:
CommentsRequest for Information 2:
Check Box4:
Check Box5:
Check Box6:
Check Box7:
Check Box8:
Check Box9:
Check Box10:
Check Box11:
Check Box12:
Check Box13:
Check Box14:
Check Box15:
Check Box16:
Check Box17:
Check Box18:
Check Box19:
Check Box20:
Check Box21:
Check Box22:
Check Box23:
Check Box24:
Check Box25:
Check Box26:
Check Box27:
Check Box28:
Check Box29: