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Maternity Preadmission Form

Section 1. Patient Information

Were you born at or have you ever been treated at Yale New Haven Hospital?
Do you have clergy members who you would like to visit you while you are in the Hospital?
*Are you expecting twins?

Obstetrician Physician Information

Primary Care Physician Information

Section 2. Nearest Legal Relative

In the event of an emergency, would you like us to notify this person?

Section 3. Patient Insurance Information

In order to make sure we properly bill your insurance company, it is important to fill out the following insurance information correctly.

Are you the subscriber?
(A subscriber is the person who carries the insurance policy)
Pre-Certification Explanation - If required, you must obtain pre-approval for your hospital admission through your insurance company prior to admission. Failure to do this may result in a penalty against your benefits. To help you complete this section you may want to refer to your insurance card.
Has Pre-certification been completed?
Are you covered under any other insurance plan?

Section 4. Hearing Impairment

All hospitals in Connecticut must provide effective communication with people who are deaf and hard of hearing. It is the policy of Yale New Haven Hospital to provide special equipment and services, including interpretation services, free of charge to patients (and their companions) who are deaf or hard of hearing, as appropriate for the delivery of medical care.

Are you deaf or hearing impaired?
Is your companion deaf or hearing impaired?

Section 5. Submit Form

Field Required