Certification Regarding Abortion Template - Iowa Department Of Human Services - 1999
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1
2Iowa Department of Human Services
CERTIFICATION REGARDING ABORTION
I. CERTIFICATION BY PHYSICIAN
CERTIFY TO ONE OF THE FOLLOWING:
I certify that on the basis of my professional judgment:
Life of the Mother (Federal Funding). ________________________________________________________________ suffers from
(Name and address of the mother)
a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused or arising from the
pregnancy itself, that would place her in danger of death unless an abortion is performed.
Life of the Mother (State Funding). The life of ___________________________________________________________________
(Name and address of the mother)
would be endangered if the fetus were carried to term.
Fetus Deformed. The fetus carried by __________________________________________________________________________
(Name and address of the mother)
is physically deformed, mentally deficient, or afflicted with a congenital illness based on: ___________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
(Medical indications)
________________________________ MD/DO
(Signature) ______________________________ Date ________________
II. CERTIFICATION BY AGENCY
1. Rape
I, ________________________________________________________, of __________________________________________ received
(Name of Official)
(Name of Agency)
a signed form from ______________________________________________________________________________________________
(Name and address of person reporting)
stating that _______________________________________________________________________ was the victim of an incident of rape.
(Name and address of the mother)
The incident took place on ______________________________ and the incident was reported on _______________________________
(Date)
(Date)
The report included the name, address and signature of the person making the report.
_______________________________________________________________________________________ Date __________________
(Signature of official of law enforcement, public or private health agency which may include a family physician)
2. Incest
I, ________________________________________________________, of __________________________________________ received
(Name of Official)
(Name of Agency)
a signed form from ______________________________________________________________________________________________
(Name and address of person reporting)
stating that ________________________________________________________________________ was the victim of an incest incident.
(Name and address of the mother)
The incident took place on ______________________________ and the incident was reported on _______________________________
(Date)
(Date)
The report included the name, address and signature of the person making the report.
_______________________________________________________________________________________ Date __________________
(Signature of official of law enforcement, public or private health agency which may include a family physician)
470-0836 (Rev. 1/99)
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