Form Hi-1 - Hysterectomy Information Form printable pdf download

Commonwealth of Massachusetts

Division of Medical Assistance

Name of Patient

600 Washington Street

(please print)

Boston, MA 02111

HYSTERECTOMY INFORMATION FORM

Instructions to Providers — Each provider requesting payment for any portion of a hysterectomy must attach a completed HI-1 form to the

claim form. When more than one provider is requesting payment for the same hysterectomy, a photocopy of the completed form may be

submitted in lieu of the original.

A. HYSTERECTOMY INFORMATION

A hysterectomy is an operation in which a woman's uterus (womb) is removed. A hysterectomy should be done

only when there is a disease or injury of the uterus (or some other medical problem) that can only be treated by

removing the uterus. Your doctor should explain to you why a hysterectomy is needed and what discomforts,

risks, and benefits may result from the surgery.

If you have a hysterectomy, you cannot become pregnant or bear children. A hysterectomy is permanent

and cannot be reversed.

MassHealth requires that a second doctor examine you before you have a hysterectomy. The reason for this

requirement is to make sure you have enough information to decide whether or not you want to have a

hysterectomy.

If the reason you are having a hysterectomy is to avoid bearing children, you should consider other methods of

sterilization, such as tubal ligation (having your tubes tied). MassHealth will not pay for a hysterectomy if the

purpose is for birth control. A hysterectomy takes much longer to do than a tubal ligation, and you would be in

the hospital longer. There is more discomfort and a greater chance of serious health problems with a

hysterectomy.

B. ACKNOWLEDGEMENT THAT HYSTERECTOMY INFORMATION WAS RECEIVED

Federal regulations (42 CFR 441.255) require that a MassHealth member having a hysterectomy sign written

acknowledgement that information about hysterectomies was received before the operation was performed.

Acknowledgement That Hysterectomy Information Was Received

I have read the above information about the hysterectomy operation. A medical person has also explained

hysterectomies to me. The discomfort, risks, and benefits that go along with a hysterectomy have been

explained to me. All of my questions have been answered to my satisfaction.

I understand that if I have a hysterectomy operation I cannot become pregnant or bear children. I

understand that a hysterectomy is permanent and cannot be reversed.

Signature of Member or Representative:

Date:

Relationship of Representative to Member:

HI-1 (Rev. 06/01)

GEN-011

Form Hi-1 - Hysterectomy Information Form