Form Hi-1 - Hysterectomy Information Form (Page 2 of 2) in pdf

Name of Physician:

Name of Patient:

(please print)

C. PHYSICIAN'S CERTIFICATION

Federal regulations (42 CFR 441.255) do not require the patient's prior acknowledgement when the patient was sterile before the

hysterectomy or in the case of emergency surgery. In such cases, the physician who performed the hysterectomy must certify in writing that

one of the following circumstances existed at the time of the surgery.

Check the appropriate box below if any of the following circumstances is applicable and complete that section of the form only.

1. Prior Sterility

I certify that the above-named member was sterile before the hysterectomy and that the cause of sterility was:

(Date of Hysterectomy)

(Signature of Physician Who Performed Hysterectomy)

(Date Signed)

2. Emergency Surgery

I certify that because of a life-threatening emergency it was not feasible or realistic to require the acknowledgement of the

above-named member before the hysterectomy. The nature of the emergency was:

(Date of Hysterectomy)

(Signature of Physician Who Performed Hysterectomy)

(Date Signed)

D. PHYSICIAN'S CERTIFICATION FOR RETROACTIVE ELIGIBILITY

Check the appropriate box below if any of the following circumstances is applicable and complete that section of the form only.

1. Retroactive Eligibility: Informed Member

The above-named patient was not a MassHealth member on the date on which the hysterectomy was performed. However, I

informed the patient before surgery that the operation would make her sterile.

(Date of Hysterectomy)

(Signature of Physician Who Performed Hysterectomy)

(Date Signed)

2. Retroactive Eligibility: Prior Sterility

The above-named patient was not a MassHealth member on the date on which the hysterectomy was performed. However, I

certify that the patient was sterile before the hysterectomy and that the cause of sterility was:

(Date of Hysterectomy)

(Signature of Physician Who Performed Hysterectomy)

(Date Signed)

3. Retroactive Eligibility: Emergency Surgery

The above-named patient was not a MassHealth member on the date on which the hysterectomy was performed. However, I

certify that because of a life-threatening emergency it was not feasible or realistic to require the patient's acknowledgement before

the hysterectomy. The nature of the emergency was:

(Date of Hysterectomy)

(Signature of Physician Who Performed Hysterectomy)

(Date Signed)

Form Hi-1 - Hysterectomy Information Form Page 2