Form Phy-81243 - Alabama Medicaid Agency Hysterectomy Consent Form Page 2
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3Hysterectomy Form Instructions
Part I.
This section is required for all routine hysterectomies. See Part III and IV for a patient who
is already sterile, a hysterectomy performed under life-threatening emergency or during a
period of retroactive Medicaid eligilbity.
•
Enter the name of the patient.
•
Enter the recipient’s 13 digit Medicaid Number.
•
Enter the diagnosis description requiring hysterectomy.
•
Enter the diagnosis code.
•
Enter the name of the representative if the recipient is unable to sign the consent
form. If a representative is not used enter N/A in the field.
•
Enter name of the physician who will perform the hysterectomy.
•
Enter the NPI Number of the physician who will perform the hysterectomy.
•
Physician must sign their name and enter the date of signature. Date must be the
date of the surgery or a prior date. If any date after surgery is recorded, the form
will be denied.
Part II.
This section is required for all routine hysterectomies. See Parts III and IV for a patient
who is already sterile, a hysterectomy performed under a life-threatening emergency or
during a period of retroactive Medicaid eligibility.
•
Enter the name of the patient and the patient’s date of birth including the
day/month/year.
•
Enter the name of representative if the recipient is unable to sign the consent form. If a
representative is not used, record N/A in this field.
•
Patient must sign and enter the date of signature unless a representative is being used
to complete the form. Date must be the date of surgery or a prior date. If any date after
surgery is recorded, the form will be denied.
•
Representative must sign and enter the date of signature if the recipient is unable to sign
the consent form. Date must be the date of the surgery or a prior date. If any date after
surgery is recorded, the form will be denied.
PART III.
This section is required for all hysterectomies.
•
Enter the date of surgery once the surgery has been performed.
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