HEALTHWAVE 21 PREGNANCY REPORT FORM	Rev. 10/03
This form is to be used to report when a HW21 beneficiary is pregnant. It should also be used when an eligibility worker learns of a change in due date or that a pregnancy terminated early. Email form to EDS at t21.duedate@ksxix.hcg.eds.com .

“HELP” information is included for each field on the status line at the bottom left of your screen or by pressing F1 in each field..
Date:
Worker name:	Worker e-mail.:
Worker location:	Worker phone:
Case No.	Beneficiary Number

(client id # with 1 after 2nd zero)
Beneficiary Name	Due Date

YYYY/MM/DD
Are you reporting a new pregnancy or a change to a pregnancy?
If pregnancy ended early, enter the date it ended

YYYY/MM/DD
Best practice for saving and using this form:

For this form to work properly, it must be “opened” in Word. It will not work if it is opened in the viewer For more information, talk to your local technical support.

First, save this document to your desktop or other folder by choosing SAVE AS from the FILE menu.

Enter your information in the appropriate fields (e.g. enter your name in the “Worker name” field. This information should be the information that you will be entering on every form.

Save the form again by choosing SAVE from the FILE menu and close it.

When you need to use the form, open the form and, from the FILE menu, choose SAVE AS before entering any additional data. Assign it a new name (e.g. you might put a “B” at the beginning of the name so you can distinguish it from the original) and choose SAVE from the FILE menu.

Complete the form, choose SAVE from the FILE menu once again, and e-mail it. You should be able to e-mail it directly from Word by choosing FILE, then SEND TO, then MAIL RECIPIENT.

If this option doesn’t work, go to Outlook and open a new note. Click on the paper clip icon, navigate to the location where you saved it (desktop is recommended), and choose the form you just completed. Enter the EDS e-mail address in the “To” line. Enter a subject, and press SEND.

Print the form you just completed and put it in the case file, then delete it from your computer.

You should be left with a form on your computer that is blank, except for the personal information that you entered and saved in the beginning.

HEALTHWAVE 21 PREGNANCY REPORT FORM

Larry McGillivary

2012-07-17

AQM

SRS - HCP