Form Phy-81243 - Alabama Medicaid Agency Hysterectomy Consent Form Page 3

Download a blank fillable Form Phy-81243 - Alabama Medicaid Agency Hysterectomy Consent Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Phy-81243 - Alabama Medicaid Agency Hysterectomy Consent Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

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.
2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3