Fillable Fa-50 Nevada Medicaid Hysterectomy Acknowledgement Form printable pdf download

Fa-50 Nevada Medicaid Hysterectomy Acknowledgement Form

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Hysterectomy Acknowledgement

Nevada Medicaid Hysterectomy Acknowledgement Form

(a) Patient Name_______________________________ (b) NV Medicaid ID#_________________________

(e) Name of Physician_________________________________ (f) NPI #_____________________________

(g) Physician’s Street Address_______________________________ (h) City, State, Zip________________

I. If the patient signs the hysterectomy acknowledgement statement PRIOR TO surgery, the

following section must be completed by the patient or her representative and physician.

I HAVE BEEN INFORMED ORALLY AND IN WRITING ON (i)_____/_____/_____ BY

(j)________________________________THAT A HYSTERECTOMY WILL RENDER ME

PERMANENTLY INCAPABLE OF BEARING CHILDREN.

(k) Date Signed_____/_____/_____ (l) Patient/Representative Signature__________________

(m) Physician Signature_________________________________

II. If the patient signs the hysterectomy acknowledgement statement AFTER surgery, the

following section must be completed by the patient or her representative and physician.

PRIOR TO MY SURGERY ON (n) ____/_____/_____, I WAS INFORMED ORALLY AND IN

WRITING BY (o) __________________________________________THAT A HYSTERECTOMY

WOULD RENDER ME PERMANENTLY INCAPABLE OF BEARING CHILDREN.

(p) Date Signed _____/_____/____(q) Patient/Representative Signature_________________

(r) Physician Signature_________________________________

III. If the patient was sterile prior to surgery OR if the hysterectomy was performed on an

emergency basis, the physician must certify such by completing ONE of the following

statements.

(MEDICAL RECORDS MUST BE ATTACHED TO DOCUMENT ITEMS C OR D)

A. Patient is sterile because she is post menopausal at age of (s)_________. Her date of birth

is (t) ____/_____/_____.

B. Patient is sterile because she has a history of previously having the sterilization procedure,

(u)________________________________________ on (v)_____/_____/_____.

C. Patient is sterile due to (w)___________________________________________________.

D. Patient required the hysterectomy and prior acknowledgement was not possible due to

the life-threatening situation of (x)_____________________________________________.

(y) Date Signed_____/_____/_____(z) Physician Signature___________________________

Updated 06/12/2015

FA-50 Nevada Medicaid Hysterectomy Acknowledgement Form

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Fa-50 Nevada Medicaid Hysterectomy Acknowledgement Form

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