POSTPARTUM INFANT and MATERNAL REFERRAL
MARYLAND POSTPARTUM INFANT and MATERNAL REFERRAL FORM
Instructions for use
This form is intended for use by Maryland hospitals to refer high risk infants and mothers at hospital discharge to their local health department for community-based services. This form replaces the former 'Infant Identification and Referral' form. It does NOT replace the 'Prenatal Risk Assessment' form.
This form should be submitted for the following conditions and circumstances:
- Teen Mother
- No prenatal care
- Substance Use/Misuse
- Mental/behavioral health
- Intimate Partner Violence
- Unstable housing/homelessness
- Previous infant death
- Previous preterm birth
- Very low birthweight (<1500grams)
- Any other circumstance deemed to be a serious risk for the mother or infant
Please note the HIPAA statement at the top of the form. Completion and submission of this form does not require patient consent since it constitutes part of coordination of health care and related services among health care providers.
Please enter all information on the form online.
Do not print the form and complete by hand. Many items have drop-down menus to select from which will make completion easier and more accurate. Completion online will also avoid handwritten responses that may be difficult to read.
Do not save a copy of the form to a personal computer as any changes or corrections will be made to the form online.
A list of all Maryland birthing hospitals is included in the drop-down menu for 'Birth Hospital.' If an infant was born out-of-state, at home, or at another location, that information can be typed in.
For items marked with one or more asterisk, additional detail can be typed in the boxes labeled 'Please specify or add comments.' Any other information deemed important may also be entered in these boxes.
For multiple births, complete the form for one infant, providing information on the sibling(s) in the 'Other Comments/Problems' box.
The form should be completed and sent close to the time of discharge so the information is still relevant and referrals are not made on infants who do not survive to discharge. If a specific referral is being made early in the hospitalization, that must be specified. The baby should be referred again close to discharge for post-discharge needs.
Page 2 of the form is a
fax cover sheet. Select the fax number from the drop-down menu for the local health department in the jurisdiction where the mother resides. Please be sure that a contact name and number, as well as the name of the referring hospital, are provided on this cover sheet.
print both the referral form and the fax cover sheet as single-sided documents. Submit both by fax to the appropriate local health department. The printed form may be kept for the medical record.
The completed form can not be saved online.
- If you have additional questions about the PIMR, please contact Anjana Rao, MHS at
firstname.lastname@example.org, and include PIMR within the subject line.
Click here to open the form (works best with Internet Explorer or Firefox browsers).