Abortion Certification Statements Form

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The signature of the physician must be original script (not stamped or typed). A copy of the signed certification
statement must be submitted with each claim for reimbursement. Faxes are not acceptable at this time.
“I, (physician’s name), certify that on the basis of my professional judgment, an abortion procedure is
necessary because (client’s full name, Medicaid number, and complete address) suffers from a physical
disorder, injury, or illness, including a life-endangering physical condition caused by or arising from the
pregnancy itself, that would place her in danger of death unless an abortion is performed.”
Signature _______________________________________________
“I, (physician’s name), certify that on the basis of my professional judgment, an abortion procedure for
(client’s full name, Medicaid number, and complete address) is necessary to terminate a pregnancy that was
the result of rape. I have counseled the client concerning the availability of health and social support services
and the importance of reporting the rape to the appropriate law enforcement authorities.”
Signature _______________________________________________
“I, (physician’s name), certify that on the basis of my professional judgment, an abortion procedure for
(client’s full name, Medicaid number, and complete address) is necessary to terminate a pregnancy that was
the result of incest. I have counseled the client concerning the availability of health and social support
services and the importance of reporting the incest to the appropriate law enforcement authorities.”
Signature _______________________________________________

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