Prenatal Care Assistance Program Annual Report
New York State Department of Health
Bureau of Women's Health
Prenatal Care Assistance Program
Annual Report for a Calendar Year
| Name of Agency: | |
| Address: | |
| Name/title of person completing report: | |
| Telephone #: ( ) | Fax #: ( ) |
| E-mail address: | Report for calendar year: |
| Data Required | Number for Calendar Year |
|---|---|
| 1. Total numberof prenatal clients for the entire calendar year (Medicaid and non-Medicaid clients combined) | |
| 2. Total number of deliveries for all prenatal clients (Medicaid and non-Medicaid clients combined) | |
| The following data is for Medicaid (or PE) clients only (0-200% of poverty) | |
| 3. Number of Medicaid clients enrolled in prenatal care on Dec. 31st | |
| 4. Total number of Medicaid clients enrolled in prenatal care during the year attending at least one prenatal visit | |
| 5. Total number of Medicaid deliveries for this year | |
| 6. Number of low birthweight babies born (<2500 gms) to Medicaid clients during this year | |
| 7. Total number of Medicaid clients with postpartum visits | |
| 8. Total number of prenatal clients on Medicaid seen this year who were less than 20 years of age | |
| 9. Total number of pregnant women on Medicaid who received HIV pretest counseling with testing | |
| 10. Total number of pregnant women on Medicaid who received HIV pretest counseling without testing | |
| 11. Total number of pregnant women on Medicaid who received HIV posttest counseling | |
| Mail, fax or e-mail by January 31st to: Please print this using 1/2 inch margins. |
Denise Hernas, PCAP Coordinator Perinatal Health Unit Bureau of Women's Health New York State Department of Health Empire State Plaza Corning Tower, Room 1882 Albany, New York 12237-0621 Telephone : 518-474-1911 Fax: 518-474-3180 E-mail: QEJ03@health.state.ny.us |
Please check here if you are unable to determine which managed care clients are on Medicaid. NOTE: These clients should still appear in your totals of prenatal clients.