Form ODM03199 "Acknowledgment of Hysterectomy Information" - Ohio

What Is Form ODM03199?

This is a legal form that was released by the Ohio Department of Medicaid - a government authority operating within Ohio. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Ohio Department of Medicaid;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ODM03199 by clicking the link below or browse more documents and templates provided by the Ohio Department of Medicaid.

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Download Form ODM03199 "Acknowledgment of Hysterectomy Information" - Ohio

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Ohio Department of Medicaid
ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION
Instructions: Complete Section I and either Section II or Section III.
Section I: Patient Information
(REQUIRED: Please type or print clearly)
1
Patient’s Name
2
Name of Patient’s Representative
(if any)
3
Patient’s 12 Digit Medicaid Number
4
Date of Hysterectomy
Section II: Provision of hysterectomy information prior to hysterectomy procedure(s)
Patient acknowledgment of receipt of hysterectomy information:
I understand that a hysterectomy (surgical removal of the uterus), whether performed as a single procedure or
together with other procedures, is medically necessary and will not be/has not been performed solely for the
purpose of making me incapable of reproducing (sterile).
Prior to the hysterectomy, I have been/was informed, both orally and in writing that the hysterectomy would
make me permanently incapable of reproducing (sterile).
5
Patient/Representative Signature
6
Date of Signature
Provider acknowledgment of provision of hysterectomy information:
Prior to the hysterectomy, I informed this patient
both orally and in
(and her authorized representative, if applicable)
writing, that the hysterectomy would make her permanently incapable of reproducing (sterile).
7
Name of Person Providing Information
8
Signature of Person Providing Information
9
Date of Signature
Section III: Physician certification of reason for not providing hysterectomy information prior to the hysterectomy
procedure.
Prior to the hysterectomy, the patient was not informed that the hysterectomy would make her permanently
incapable of reproducing (sterile) because:
(check all that apply, please type or print clearly, do not provide additional
attachments)
10
She was already sterile before the hysterectomy (please briefly explain cause of the sterility):
11
The hysterectomy was performed under a life-threatening emergency situation in which prior provision of
information was not possible (please describe the nature of the emergency):
12
Name of the physician who performed the hysterectomy
(please type or print clearly)
13
Signature of the physician who performed the hysterectomy
14
Date of Signature
FOR REIMBURSEMENT, EACH PROVIDER MUST INCLUDE A COPY OF THIS COMPLETED FORM WITH CLAIM FOR SERVICES
Distribution: One copy to patient, one copy retained by facility; one copy retained by physician; one copy retained by anesthesiologist.
ODM 03199 (8/2017)
Ohio Department of Medicaid
ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION
Instructions: Complete Section I and either Section II or Section III.
Section I: Patient Information
(REQUIRED: Please type or print clearly)
1
Patient’s Name
2
Name of Patient’s Representative
(if any)
3
Patient’s 12 Digit Medicaid Number
4
Date of Hysterectomy
Section II: Provision of hysterectomy information prior to hysterectomy procedure(s)
Patient acknowledgment of receipt of hysterectomy information:
I understand that a hysterectomy (surgical removal of the uterus), whether performed as a single procedure or
together with other procedures, is medically necessary and will not be/has not been performed solely for the
purpose of making me incapable of reproducing (sterile).
Prior to the hysterectomy, I have been/was informed, both orally and in writing that the hysterectomy would
make me permanently incapable of reproducing (sterile).
5
Patient/Representative Signature
6
Date of Signature
Provider acknowledgment of provision of hysterectomy information:
Prior to the hysterectomy, I informed this patient
both orally and in
(and her authorized representative, if applicable)
writing, that the hysterectomy would make her permanently incapable of reproducing (sterile).
7
Name of Person Providing Information
8
Signature of Person Providing Information
9
Date of Signature
Section III: Physician certification of reason for not providing hysterectomy information prior to the hysterectomy
procedure.
Prior to the hysterectomy, the patient was not informed that the hysterectomy would make her permanently
incapable of reproducing (sterile) because:
(check all that apply, please type or print clearly, do not provide additional
attachments)
10
She was already sterile before the hysterectomy (please briefly explain cause of the sterility):
11
The hysterectomy was performed under a life-threatening emergency situation in which prior provision of
information was not possible (please describe the nature of the emergency):
12
Name of the physician who performed the hysterectomy
(please type or print clearly)
13
Signature of the physician who performed the hysterectomy
14
Date of Signature
FOR REIMBURSEMENT, EACH PROVIDER MUST INCLUDE A COPY OF THIS COMPLETED FORM WITH CLAIM FOR SERVICES
Distribution: One copy to patient, one copy retained by facility; one copy retained by physician; one copy retained by anesthesiologist.
ODM 03199 (8/2017)