Form Map-251 - Hysterectomy Consent Form

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MAP-251
Commonwealth of Kentucky
(Rev. 10/2010)
CABINET FOR HEALTH AND FAMILY SERVICES
Department for Medicaid Services
HYSTERECTOMY CONSENT FORM
_______________________________________
___________________
Medicaid Recipient Name
Medicaid ID #
____________________________________________
_____________
Physician’s Name
Date of Hysterectomy_
>>>>COMPLETE ONLY ONE OF THE REMAINING SECTIONS & COMPLETE ALL BLANKS IN SECTION<<<<
SECTION A:
COMPLETE THIS SECTION FOR RECIPIENT WHO ACKNOWLEDGES RECIEPT
PRIOR TO HYSTERECTOMY
I HAVE BEEN INFORMED ORALLY AND IN WRITING THAT A HYSTERECTOMY WILL RENDER ME PERMANENTLY
INCAPABLE OF REPRODUCING.
___________________________________________________________________________________
PATIENT’S SIGNATURE
DATE
_______________________________________________________________________________________________________
WITNESS’ SIGNATURE
DATE
SECTION B:
COMPLETE THIS SECTION WHEN ANY OF THE EXCEPTIONS LISTED BELOW IS
APPLICABLE. CHECK ONLY ONE SELECTION.
I certify that before I performed the hysterectomy procedure on the recipient listed below:
1 [ ] I
informed her that this operation would make her permanently incapable of reproducing. (This certification for
retroactively eligible recipient only – a copy of the Medicaid card which covers the date of the hysterectomy, or
a copy of the retroactive approval notice, must accompany this form before the reimbursement can be made.)
2 [ ] She
__________________________________________________________
was already sterile due to
______________________________________________________________________________
CAUSE OF STERLITY
3 [ ] She
had a hysterectomy performed because of a life-threatening situation due to ________________________________
______________________________________________________________________________
DESCRIBE EMERGENCY SITUATION
And the information concerning sterility could not be given prior to the hysterectomy. Life-threatening should indicate that
the patient is unable to respond to the information pertaining to the acknowledgement agreement.
____________________________________________________________________________________
PHYSICIAN’S SIGNATURE
DATE
SECTION C:
COMPLETE THIS SECTION FOR MENTALLY-INCOMPETENT RECIPIENT ONLY
I acknowledge receipt of information, both orally and in writing, prior to the hysterectomy’s being performed, that if a hysterectomy
is performed on the above recipient, it will render her permanently incapable of reproducing.
_____________________________________________________ ___________________________________________________
WITNESS’ SIGNATURE
DATE
PATIENT REPRESENTATIVE SIGNATURE
DATE
PHYSICIAN’S STATEMENT
I affirm that the hysterectomy I performed on the above recipient was medically necessary due to ___________________________
_________________________________________________________________________________________________________
REASON FOR HYSTERECTOMY
And was not done for sterilization purposes, and that to the best of my knowledge the individual on whom the hysterectomy was
performed is mentally incompetent. Before I performed the hysterectomy on her I counseled her representative, orally and in writing
that the hysterectomy would render that individual permanently incapable of reproducing; and the individual’s representative has
signed a written acknowledgement of receipt of the foregoing information.
_________________________________________________________________________________________________________
PHYSICIAN’S SIGNATURE
DATE

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