"Acknowledgment/Certification Statement for a Hysterectomy - Colorado Medical Assistance Program" - Colorado

"Acknowledgment/Certification Statement for a Hysterectomy - Colorado Medical Assistance Program" - Colorado Download Pdf
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Acknowledgment/Certification Statement for a Hysterectomy - Colorado Medical Assistance Program is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on November 1, 2017;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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C
M
A
P
S
H
OLORADO
EDICAL
SSISTANCE
ROGRAM
TATEMENT FOR
YSTERECTOMY
Acknowledgment/Certification Statement for a Hysterectomy
Section I or Section II of this form must be completed and attached to all claims for payment.
Section I. (Member information)
Do not complete this section if:
The member was already sterile at the time of the hysterectomy
The hysterectomy was performed because of a life threatening emergency and prior acknowledgment by
the member was not possible.
Member’s name:
Member’s address:
Colorado Medical Assistance Program State ID number:
Date of service:
I have asked for and received information about the hysterectomy from:
(name of doctor or clinic)
I understand that a hysterectomy is being performed for medical reasons. I acknowledge that prior to surgery I was
advised that a hysterectomy is a procedure that will render me permanently incapable of bearing children.
Member’s or representative’s signature
Date
Section II. (Physician information)
This section must be completed by the physician performing the hysterectomy if:
The member was already sterile at the time of the hysterectomy
The hysterectomy was performed because of a life threatening emergency and prior acknowledgment by
the member was not possible.
Colorado Medical Assistance
Physician’s name:
Program provider number:
Colorado Medical Assistance
Member’s name:
Program State ID number:
Please check and complete the paragraph that applies to this member:
I certify that the above named member was already sterile at the time of the hysterectomy. The sterility was due
to:
I certify that the above named memberrequired a hysterectomy under a life-threatening, emergency situation.
During the emergency, I determined that prior acknowledgment by the patient was not possible. A description of
the nature of the emergency follows:
Physician’s signature
Date
Revised: 11/17
C
M
A
P
S
H
OLORADO
EDICAL
SSISTANCE
ROGRAM
TATEMENT FOR
YSTERECTOMY
Acknowledgment/Certification Statement for a Hysterectomy
Section I or Section II of this form must be completed and attached to all claims for payment.
Section I. (Member information)
Do not complete this section if:
The member was already sterile at the time of the hysterectomy
The hysterectomy was performed because of a life threatening emergency and prior acknowledgment by
the member was not possible.
Member’s name:
Member’s address:
Colorado Medical Assistance Program State ID number:
Date of service:
I have asked for and received information about the hysterectomy from:
(name of doctor or clinic)
I understand that a hysterectomy is being performed for medical reasons. I acknowledge that prior to surgery I was
advised that a hysterectomy is a procedure that will render me permanently incapable of bearing children.
Member’s or representative’s signature
Date
Section II. (Physician information)
This section must be completed by the physician performing the hysterectomy if:
The member was already sterile at the time of the hysterectomy
The hysterectomy was performed because of a life threatening emergency and prior acknowledgment by
the member was not possible.
Colorado Medical Assistance
Physician’s name:
Program provider number:
Colorado Medical Assistance
Member’s name:
Program State ID number:
Please check and complete the paragraph that applies to this member:
I certify that the above named member was already sterile at the time of the hysterectomy. The sterility was due
to:
I certify that the above named memberrequired a hysterectomy under a life-threatening, emergency situation.
During the emergency, I determined that prior acknowledgment by the patient was not possible. A description of
the nature of the emergency follows:
Physician’s signature
Date
Revised: 11/17
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"Acknowledgment/Certification Statement for a Hysterectomy - Colorado Medical Assistance Program" - Colorado Download Pdf
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