Form Ldss-3113 - Acknowledgement Of Hysterectomy Information printable pdf download

LDSS-3113

(4/84)

ACKNOWLEDGEMENT OF HYSTERECTOMY INFORMATION

RECIPIENT ID NO.

SURGEON’S NAME

(NYS MEDICAID PROGRAM)

EITHER PART I OR PART II MUST BE COMPLETED

RECIPIENT’S ACKNOWLEDGMENT STATEMENT AND SURGEON’S CERTIFICATION

PART I:

RECIPIENT’S ACKNOWLEDGMENT STATEMENT

It has been explained to me,

that the hysterectomy to be performed on me

(RECIPIENT NAME)

will make it impossible for me to become pregnant or bear children. I understand that a hysterectomy is a permanent

operation. The reason for performing the hysterectomy and the discomforts, risks and benefits associated with the

hysterectomy have been explained to me and all my questions have been answered to my satisfaction prior to the

surgery.

RECIPIENT OR REPRESENTATIVE SIGNATURE

DATE

INTERPRETER’S SIGNATURE (If required)

DATE

SURGEON’S CERTIFICATION

The hysterectomy to be performed for the above mentioned recipient is solely for medical indications.

The

hysterectomy is not primarily or secondarily for family planning reasons, that is, for rendering the recipient

permanently incapable of reproducing.

SURGEON’S SIGNATURE

DATE

WAIVER OF ACKNOWLEDGMENT AND SURGEON’S CERTIFICATION

PART II:

The hysterectomy performed on

was solely for medical indications.

(RECIPIENT NAME)

The hysterectomy was not primarily or secondarily for family planning reasons, that is, for rendering the recipient

permanently incapable of reproducing. I did not obtain Acknowledgement of Receipt of Hysterectomy information

from her and have her complete Part I of this form because (please check the appropriate statement and describe

the circumstances where indicated):

1. She was sterile prior to the hysterectomy.

(briefly describe the cause of sterility)

2. The hysterectomy was performed in a life threatening emergency in which prior acknowledgment

was not possible. (briefly describe the nature of the emergency)

______________________________________________________________________________

3. She was not a Medicaid recipient at the time the hysterectomy was performed but I did inform her

prior to surgery that the procedure would make her permanently incapable of reproducing.

SURGEON’S SIGNATURE

DATE

DISTRIBUTION:

File patient’s medical record; hospital submit with claim for payment; surgeon and anesthesiologist

submit with claims for payment; patient.

Form Ldss-3113 - Acknowledgement Of Hysterectomy Information

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