Fillable Form Phy-81243 - Alabama Medicaid Agency Hysterectomy Consent Form printable pdf download

Form Phy-81243 - Alabama Medicaid Agency Hysterectomy Consent Form

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ATTACHMENT I

ALABAMA MEDICAID AGENCY HYSTERECTOMY CONSENT FORM

See the back of this form for instructions on completing and submitting the form

PART I.

P H Y S I C I A N

Certification by Physician Regarding Hysterectomy

I hereby certify that I have advised

Medicaid Number

Name of Patient

undergo a hysterectomy because of the diagnosis of

diagnosis code

Further, I have explained orally and in writing to this patient and/or her representative (

) that she will be

Name of Representative, if any

permanently incapable of reproducing as a result of this operation which is medically necessary. This explanation was given before the

operation was performed.

Name of Physician

NPI #

Signature of Physician

Date of Signature

PART II.

P A T I E N T

Acknowledgment by Patient (and/or Representative) of Receipt of Above Hysterectomy Information

and/or

hereby acknowledge that

Name of Patient

Date of Birth

Name of Representative, if any

I have been advised orally and in writing that a hysterectomy will render me permanently incapable of reproducing and that I have agreed

to this operation. This oral and written explanation that the hysterectomy would make me sterile was given to me before the operation.

Signature of Patient

Date

Signature of Representative, if any

Date

PART III.

P H Y S I C I A N

Date of Surgery ______________________________

PART IV.

U N U S U A L C I R C U M S T A N C E S

Recipient Name: ___________________________

Recipient ID: _______________________

I ________________________________ certify

Printed name of physician

patient was already sterile when the hysterectomy was performed. Cause of sterility __________________________________.

Medical records are attached.

hysterectomy was performed under a life threatening situation. Medical records are attached.

hysterectomy was performed under a period of retroactive Medicaid eligibility. Medical records are attached.

Before the operation was performed, I informed the recipient that she would be permanently incapable of reproducing as a result of this

operation.

Yes

Signature: ___

_________________________________ Date: ____

_________________

PART V.

S T A T E R E V I E W D E C I S I O N

Signature of Reviewer: ______________________________

Date of Review: ____________

Deny

Pay

Reason for denial:

______________________________________

PHY-81243 (Revised 09-29-20 6)

Alabama Medicaid Agency

Form Phy-81243 - Alabama Medicaid Agency Hysterectomy Consent Form

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