Get Certification For Induced Abortion - Michigan

Filling out the CERTIFICATION FOR INDUCED ABORTION form is a crucial process for ensuring proper documentation and eligibility for Medicaid and related programs. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and effectively.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Enter the beneficiary's full name in the designated field as it appears on official documents.
3. Provide the MIHealth Number or MIChild Number associated with the beneficiary to ensure accurate identification.
4. Record the date of service, ensuring you use the correct format (month, day, year).
5. Fill in the beneficiary's address, including street number, street name, and apartment/lot number if applicable.
6. Specify the city, state, and ZIP code of the beneficiary’s residence.
7. Select the appropriate box indicating the reason for payment — either the life of the mother is endangered or the pregnancy resulted from rape or incest.
8. If applicable, list the medical condition(s) that would endanger the mother if the pregnancy were to continue.
9. Indicate whether a police report was filed by selecting 'YES' or 'NO'. If 'NO', provide an explanation as needed.
10. Confirm if a report was filed with the local Department of Health and Human Services office by choosing 'YES' or 'NO'. Again, if 'NO', include an explanation.
11. Please note that filing a report is not required for payment eligibility.
12. The physician must sign the form by hand, including their typed or printed name below the signature.
13. Fill in the physician's office address, city, state, and ZIP code.
14. Enter the Provider NPI Number assigned to the physician.
15. Finally, record the date the form is signed before submitting it.
16. Once all fields are complete, save your changes, and download, print, or share the completed form as necessary.

Complete your CERTIFICATION FOR INDUCED ABORTION form online for a smooth submission process.