What Is Typically Included on a Verification of Pregnancy Form?


Quick Answer

A pregnancy verification form provides space for an applicant to fill in her name, address, date of expected delivery, anticipated number of births and the month pregnancy began, explains the Texas Health and Human Services Commission. A space is provided for a medical professional to sign and verify the pregnancy.

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Full Answer

Pregnancy verification forms help with determining eligibility for financial assistance, medical care or food stipends provided by state organizations, according to the Texas Health and Human Services Commission. A medical professional, such as a nurse practitioner, physician, registered nurse or medical professional approved by a physician, must provide contact information and verification of the pregnancy.

A pregnancy verification form may also include an option for expectant mothers to indicate if they are exempt from working during the pregnancy, according to the Texas Health and Human Services Commission. Applicants must also sign to allow the state department permission to contact the medical professional and discuss the patient’s health condition.

Individuals who do not have access to a medical professional can often opt to take a pregnancy test at a state agency, explains the Illinois Department of Health and Human Services. State departments often work with free clinics, Planned Parenthood offices and social service agencies who perform pregnancy tests. A pregnancy verification form is typically filled out after the pregnancy test is performed.

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