BABY PHASES... Whether You Are Pregnant Now Or Just Thinking About It.

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1 BABY PHASES... Whether You Are Pregnant Now Or Just Thinking About It. Healthchoice and the Winnie Palmer Hospital for Women & Babies Maternal Education and Breastfeeding Education Center offer an exceptional benefit to Healthchoice members who are currently pregnant or planning on becoming pregnant. Baby Phases, part of the Healthy U initiative, provides expectant team members and their spouse dependents with the education and support needed as they prepare for the arrival of their baby. The Baby Phases program also offers financial incentives for joining and completing the required program. Requirements include attending the following childbirth education classes: Preparing for a Healthy Baby is scheduled for our preconception members and those in their first trimester of pregnancy. Topics of discussion include pregnancy as wellness, protecting your unborn child, and coping with the physical discomforts of early pregnancy. The Baby Inside You Scheduled during the second trimester, class discussion will include topics such as relaxation techniques, preterm labor recognition, sexuality during pregnancy, planning for birth, nutrition and exercise, and infant care issues. Preparation for Labor & Birth. Finally, in the third trimester, this class provides the mother and coach with information about labor and delivery, birthing options, pain relief, Cesarean birth and recovery.

2 Baby Phases Program Financial Benefits Team member incentives are based on enrollment date and completion of the program. Enrollment can begin as early as one year prior to becoming pregnant, up until the 28th week of pregnancy. The earlier the enrollment, the greater the financial benefit. When You Enroll And Complete... You Will Receive Preconception: Up to 12 months before pregnancy Preparing for a Healthy Baby Health Interviews Each Trimester $225* Pregnancy: Up to the 12th week Preparing for a Healthy Baby Health Interview Each Trimester $175* Pregnancy: 13th to 28th week Health Interview Each Trimester $50* *subject to tax added. Additional Baby Phases benefits, not required for completion, include: Free childbirth education refresher classes for second- and third-time Baby Phases participants Lactation consultant support Back to Work consultation For more information call Healthchoice at or /15

3 HEALTHCHOICE BABY PHASES PROGRAM ENROLLMENT PROCESS 1. Read Informed Consent, check YES or NO and complete contact information at the bottom of page. 2. Complete Baby Phases Initial Assessment in entirety 3. Fax forms to Healthchoice at (321) or completed forms to: R to be enrolled in the free BABY PHASES program. 4. Once the forms are received, Priscilla Ramos will contact you by phone to complete the enrollment process which includes registration for mandatory child birth classes at Winnie Palmer Hospital. Enrollment is not complete until you are registered for the classes by Priscilla. BABY PHASES INFORMED CONSENT I understand the Baby Phases program will provide me with the education and support needed to prepare for the arrival of my baby. I understand that the amount of the Baby Phases financial incentive that I am eligible to receive is based upon enrollment date and completion of the program. I understand and agree to participate in all mandatory child birth education classes offered at Winnie Palmer Hospital and health interviews in order to complete the Baby Phases program and be eligible for the financial incentive. I understand the mandatory classes include the following: First time participant of Baby Phases Preparing for a Healthy Baby (for those enrolling during preconception up to 12 week of pregnancy only), The Baby Inside You, Preparation for Birth (Lamaze) Second time or repeat participant Basic Infant Care and Parent s Night I understand that it is my responsibility to contact Priscilla Ramos at or R to register, cancel and/or reschedule mandatory child birth education classes. Classes not attended without prior notification will result in an automatic disenrollment from the Baby Phases program. I understand upon completion of the program, I will receive a check for the full incentive amount from Coresource. The financial incentive will be subject to tax and will be deducted from my Orlando Health paycheck. I acknowledge that I have read this form in its entirety and I understand my responsibility in participating in the Baby Phases program and accept all rule and regulations set forth. Print Name: Signature: Date: Mailing Address: Team Member ID or Dependent Member ID: Contact Information: Phone

4 Baby Phases Initial Assessment Complete the form in entirety and fax to or the form to R to be enrolled in Baby Phases Program Full Name: Team member/dependent ID Mailing Address: Phone Number(s): How old are you? What is your date of birth? Are you pregnant? Yes No If yes, how many weeks pregnant are you? 1 13 weeks weeks 28 weeks What is your expected due date? If no, when are you planning on becoming pregnant? Do you have an ob/gyn? Yes No If yes, who is your ob/gyn? When is your next appointment with your doctor? What is or was your pre pregnancy weight? [ ] Pounds How much weight have you gained from your pre pregnancy weight? This pregnancy is my first second third fourth (other) Give date your last pregnancy ended: Date: (month/year) Please mark any of the following that may have happened during your last pregnancy. Had a baby that was not born alive Had a baby born 3 weeks or more before due date Had a baby that weighed less than 5 pounds, 8 ounces None of the above 1

5 Did you have any of the following problems during your last pregnancy? For each item, answer (Yes) if you had the problem or answer N (No) if you did not. Cervix had to be sewn shut (cerclage for incompetent cervix) Yes No High blood pressure, hypertension (including pregnancy induced hypertension [PIH]), preeclampsia, or toxemia Yes No Gestational diabetes (diabetes during the pregnancy) Yes No Problems with the placenta (such as abruptio placentae or placenta previa) Yes No Labor pains more than 3 weeks before my baby was due (preterm or early labor) Yes No Water broke more than 3 weeks before my baby was due (premature rupture of membranes [PROM] Yes No Has any doctor, nurse, or other health care worker talked with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each item, answer Y (Yes) if someone talked with you about it or answer N (No) if no one talked with you about it. How smoking during pregnancy could affect my baby Yes No Breastfeeding my baby Yes No How drinking alcohol during pregnancy could affect my baby Yes No Medicines that are safe to take during my pregnancy Yes No How using illegal drugs could affect my baby Yes No Doing genetic tests to screen for birth defects or diseases that run in my family Yes No The signs and symptoms of preterm labor (labor more than 3 weeks before the baby is due) Yes No The signs and symptoms of pregnancy induced hypertension [PIH]), preeclampsia, or toxemia Yes No Risk factors and screening of gestational diabetes Yes No What to do if my labor starts early Yes No Getting tested for HIV (the virus that causes AIDS) Yes No What to do if I feel depressed during my pregnancy or after my baby is born Yes No 2

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