"Certification Statement/Case Summary - Colorado Medical Assistance Program" - Colorado

Certification Statement/Case Summary - 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 October 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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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable 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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Download "Certification Statement/Case Summary - Colorado Medical Assistance Program" - Colorado

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C
M
A
P
A
– L
M
OLORADO
EDICAL
SSISTANCE
ROGRAM
BORTION
IFE OF
OTHER
Certification Statement/Case Summary
Abortion Services (Life Endangering Circumstances)
ALL requested information on this form must be completed in its entirety and the form
submitted for processing with abortion claims.
Section I. Member Information
1. Member Medicaid ID:
2. Member Name:
3. Member Address:
4. Age of Member:
5. Gestational Age of Fetus:
Section II. Practitioner Information
Condition for which procedure was performed:
To save the life of the mother due to a physical disorder, physical injury, or physical illness, including a life-
endangering physical condition caused by or arising from the pregnancy itself.
To save the life of the mother based on psychiatric condition.*
*A psychiatric evaluation from a physician, confirming the presence of a life-endangering psychiatric
condition, is required for payment. Please submit this documentation as an attachment to this form.
Description of medical condition necessitating abortion:
Description of services and procedure code(s) billed:
Name of facility where abortion services were rendered:
Date service(s) were rendered:
Section III. Additional required documentation
To confirm life endangering circumstances, at least 1 of the following documents must be included with the
claim. Please mark the documents submitted:
Hospital admissions summary
Hospital discharge summary
Consultant findings and reports
Lab results and findings
Office visit notes
Hospital progress notes
Section III. Signatures
Physician's Signature
Physician's Medicaid ID
Date
Attending Practitioner Signature
Attending Practitioner Medicaid ID
Date:
(if applicable)
Revised: 10/17
C
M
A
P
A
– L
M
OLORADO
EDICAL
SSISTANCE
ROGRAM
BORTION
IFE OF
OTHER
Certification Statement/Case Summary
Abortion Services (Life Endangering Circumstances)
ALL requested information on this form must be completed in its entirety and the form
submitted for processing with abortion claims.
Section I. Member Information
1. Member Medicaid ID:
2. Member Name:
3. Member Address:
4. Age of Member:
5. Gestational Age of Fetus:
Section II. Practitioner Information
Condition for which procedure was performed:
To save the life of the mother due to a physical disorder, physical injury, or physical illness, including a life-
endangering physical condition caused by or arising from the pregnancy itself.
To save the life of the mother based on psychiatric condition.*
*A psychiatric evaluation from a physician, confirming the presence of a life-endangering psychiatric
condition, is required for payment. Please submit this documentation as an attachment to this form.
Description of medical condition necessitating abortion:
Description of services and procedure code(s) billed:
Name of facility where abortion services were rendered:
Date service(s) were rendered:
Section III. Additional required documentation
To confirm life endangering circumstances, at least 1 of the following documents must be included with the
claim. Please mark the documents submitted:
Hospital admissions summary
Hospital discharge summary
Consultant findings and reports
Lab results and findings
Office visit notes
Hospital progress notes
Section III. Signatures
Physician's Signature
Physician's Medicaid ID
Date
Attending Practitioner Signature
Attending Practitioner Medicaid ID
Date:
(if applicable)
Revised: 10/17