PEHP WeeCare Enrollment

Learn More About PEHP WeeCare

Relation to Policy Holder

What is your relationship to the Policy Holder

Name and Personal

First Name First Name is required

Last Name Last Name is required

Birth Date Birth Date is required

Address and Contact Info

Street Street is required

City City is required

State State is required

Zipcode Zipcode is required

Email Address

Phone Number Phone Number is required

Type of Phone Number Provided Required

Questionnaire

Number of Previous Pregnancies
(including miscarriages and abortions)

Did you have any problems or complications with your previous pregnancies?

Yes

Please describe any complications you encountered in your previous pregnancies

Did any of the newborns have problems or complications?

Yes

Please give description

Do you have ongoing health concerns?

Yes

Please give description

Do you take any medications, including over-the counter medications, prescription medications, vitamins, herbs, or dietary supplements?

Yes

Please give description

Do you use tobacco products, drink alchoholic beverages, or use any recreational drugs?

Yes

Please give description

Are you aware of any problems or concerns with this pregnancy?

Yes

Please give description

Do you have additional health insurance policies?

Yes

Please enter information about additional health insurance policies, if any

Delivery Information

Do you know your estimated due date?

Yes

Estimated Due Date

First Day of Last Period

Physician or Midwife's Full Name

Are you receiving prenatal care?

Yes

First Prenatal Care Appointment Date

Anticipated Delivery Hospital

Telephone Interview

As part of your enrollment in WeeCare, we will schedule a brief telephone inteview. The WeeCare program will be explained and your questions answered. Interview calls are done on Mondays and Wednesdays from 9:00 AM to 4:30 PM. Please list your availability below so we can schedule your appointment. (If there are no times on Monday and Wednesday that will work for you, please indicate below, and we will try our best to accommodate you at another time.) Please indicate what phone number we should use to reach you for your telephone interview.

Availability

May we contact you with the Phone Number you provided?

Yes

No, use other Phone Number

Phone Number for telephone interview

PEHP Customer Service Line:
801-366-7555 or 800-765-7347 (TTY:711)