Form H3037, Report of Pregnancy

Instructions

Updated: 4/2003

Purpose

• To document pregnancy, the sixth to ninth months, delivery date, multiple births, and other disabling conditions related to pregnancy.
• To obtain client's permission for information release.

Procedure

When to Prepare

The advisor prepares Form H3037 to verify

• that a client is pregnant.
• the sixth to ninth months of pregnancy.
• disabling conditions caused by the pregnancy.
• multiple births.

Number of Copies

Original and two copies.

Transmittal

Advisor — If the client has a physician, nurse, or advanced nurse practitioner she has seen or plans to see for her pregnancy, send the original and one copy to the physician, advanced nurse practitioner, registered nurse, or other medical professional (under physician's orders) with a self-addressed return-mail envelope. If the client has no physician, advanced nurse practitioner, registered nurse, or other medical professional (under physician's orders), give all copies and a self-addressed return-mail envelope to the client and inform her to give the form and envelope to the physician, advanced nurse practitioner, registered nurse, or other medical professional (under physician's orders) she sees.

Physician/Advanced Nurse Practitioner/Registered Nurse/Other Medical Professional (under physician's orders) — Instructions for completing and returning are included on the form.

Advisor — If the form is not returned within 10 days after sending it, contact the physician, advanced nurse practitioner, registered nurse, or other medical professional (under physician's orders) or, if applicable, the client, and request that it be returned as soon as possible.

Form Retention

Keep Form H3037 in the case record according to the instructions in the Texas Works Manager's Guide.

Detailed Instructions

The advisor

• enters the patient's name and the case name and number,
• marks items to be completed by the physician, advanced nurse practitioner, registered nurse, or other medical professional (under physician's orders),
• obtains the client's signature for information release,
• enters his address and telephone number, and
• signs the form.

The physician, advanced nurse practitioner, registered nurse, or other medical professional (under physician's orders)

• completes items marked;
• signs and dates the form;
• enters his name, address, and telephone number; and
• returns the form to the advisor.

The client

• enter patient's name;
• enters doctor, medical facility, or health care provider authorized to release information;
• enters expiration date or event that relates to the individual; and
• signs and dates the form.
• If a personal representative signs the form, refer to handbook Item B-1212 for definitions.
• describe why the representative has the authority to represent the client. Refer to handbook Item B-1212 for definitions.
• enter signatures of two witnesses, if required.

When the form is received, ensure that it is signed and dated. If the form is completed and signed by a medical professional other than a physician, advanced nurse practitioner, or registered nurse, ensure that the information concerning the supervising physician is completed.