Get Form Ldss 3113

Filling out the Form Ldss 3113 online is a crucial step for recipients undergoing a hysterectomy, ensuring all necessary acknowledgments and certifications are properly documented. This guide will provide clear, step-by-step instructions to help you navigate each section of the form.

Follow the steps to complete the Form Ldss 3113 online

1. Click the ‘Get Form’ button to access the document and open it in the editor.
2. In Part I, begin by entering the recipient’s name in the designated field. Review the acknowledgment statement carefully, ensuring all explanations regarding the hysterectomy are clear and understood.
3. The recipient or their representative should sign and date the acknowledgment statement. If an interpreter assisted in the explanation, their signature and date should also be provided in the specified area.
4. Next, complete the surgeon’s certification section. The surgeon must affirm that the hysterectomy is performed solely for medical reasons and not for family planning. The surgeon’s signature and date are required.
5. If you are using Part II instead, ensure to document the recipient's name. This section will require selecting the appropriate reasons for not obtaining acknowledgment, as outlined in the provided choices. You may need to provide a brief description relevant to the selected statement.
6. The surgeon must sign and date the waiver section as well, confirming the details provided are accurate.
7. Once all sections are completed, you can save your changes, download a copy of the form, print it, or share it as needed.

Complete your forms online today for a smoother processing experience.