PART IV.
This section is for use when a hysterectomy was performed on a patient who was already
sterile, under a life-threatening emergency in which prior acknowledgement was not possible or
during a period of retroactive Medicaid eligibility. Medical records must be submitted for any
hysterectomy recorded under this section. In lieu of this form, a properly executed informed
consent and medical records may be submitted for these three circumstances.
•
Enter name of the patient.
•
Enter the recipient’s 13 digit Medicaid Number.
•
Enter the name of the physician who performed the surgery.
•
Check the appropriate box to indicate the specific unusual circumstance.
•
Check the appropriate box regarding whether or not the patient was
informed she would be permanently incapable of reproducing as a
result of the operation.
•
Physician must sign their name and enter the date of signature.
PART V.
The reviewer at the State completes this section whenever unusual circumstances are identified.
HPE will send a copy of the consent form containing the State payment decision to the
surgeon following State review.
SUBMISSION INSTRUCTIONS:
Effective October 26, 2016, the physician must submit this form via Provider Web Portal upload
or fax with supporting medical records (Medical History, Operative Records, Discharge
Summary and a Hospital Consent Form for Hysterectomy) and claim to HPE.
Refer to Chapter 5 (Filing Claims) for instructions on the digital submission of the Hysterectomy
.
Consent Form and supporting documentation
NOTE: If submitting this form via fax, a barcode fax coversheet is required with each
submission and should be included as page one of the fax transmission for the
corresponding Record ID.
Fax form to HPE at: (334) 215-7416.
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