7.4.4.2 ARP Medical Information Requirements

The required medical information/verification for ARP must be provided through either:

The At Risk Pregnancy (ARP) Medical Information/Verification form (4070) ; or

A letter from the physician on the physician’s letterhead that includes all of the medical information listed below.

ARP medical information must include all of the following:

Participant’s full name;

Participant’s date of birth;

Participant’s estimated due date, provided by the participant’s physician;

Physician’s confirmation that the participant has an at-risk pregnancy;

Physician’s statement of the reason the participant’s pregnancy is an at-risk pregnancy;

Physician’s statement that the participant is unable to work due to the at-risk pregnancy;

Start date for the participant being unable to work due to the at-risk pregnancy;

Any other comments by the physician;

Physician’s specialty which must be General Medicine, Family Medicine or Obstetrics;

Physician’s National Provider Identifier (NPI);

Physician’s signature and printed name;

Date of the physician’s signature (must be no earlier than 30 days prior to the participant’s third trimester start date); and

Physician’s contact information.

Note : The W-2 agency may verify an NPI using the NPI Registry.

The physician-provided medical information/verification must be based on the physician’s medical examination of the participant.

The physician’s signed statement on either the ARP Medical Information/Verification form (4070) or on the physician’s letter must be completed no earlier than 30 days prior to the beginning of the participant’s third trimester of pregnancy. Medical information/verification completed earlier must be resubmitted and updated by the physician within the required time frame.

The W-2 agency must date stamp the ARP Medical Information/Verification form (4070) or the physician’s letter with the date the agency received the document.

EXAMPLE : Christa is pregnant with her first child and is currently on bed rest because her pregnancy is high risk. Christa applies for W-2 while still in her first trimester and is placed in a CMP placement. Christa’s medical condition could change between her first trimester and her third trimester when she may become eligible for an ARP placement. Therefore, Christa will need updated medical information/verification no earlier than 30 days prior to the beginning of her third trimester of pregnancy to be eligible for the ARP placement.