S. Lee Woods, M.D., Ph.D. Director, Office of Surveillance and Quality Initiatives Maternal and Child Health Bureau Prevention and Health Promotion Administration Maryland Department of Health and Mental Hygiene

referral.aspx Purpose: 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: Low birthweight birth ( 2500 gm) NICU admission Teen mother No prenatal care Maternal substance abuse Previous infant death Any other circumstance deemed to be a risk for mother or infant

Under HIPAA, a health care provider may disclose protected health information (PHI) to another provider or to a covered entity, including a managed care organization or other health plan, to facilitate treatment, including the provision, coordination, or management of health care and related services by one or more health care providers, without the authorization of an individual. 45 C.F.R. § , § and § (c)(1) and (2). In addition, HIPAA permits a health care provider to disclose PHI, without the authorization of an individual, to public health authorities -- such as local health departments and family health administration programs of the Maryland Department of Health and Mental Hygiene -- that are authorized by law to collect or receive such information for the purposes of preventing or controlling disease, injury or disability, including but not limited to the reporting of disease, injury, or vital events such as birth or death, and conducting public health surveillance. 45 C.F.R. § Therefore, patient authorization is not required to complete and submit this form by facsimile, encrypted , or other secure means, to the designated health care provider, health plan, or public health authority.

Purpose: 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. It is not intended for referral for medical services.

This form should be submitted for the following conditions and circumstances: Teen Mother Mental health issue Previous infant death No prenatal care Domestic Violence Previous preterm birth Substance Abuse Unstable housing / Very low birthweight homelessness (<1500g) Any other circumstance deemed to be a serious risk for mother or infant.

Questions?