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TATEMENT AND SURGEON S CERTIFICATION RECIPIENT S ACKNOWLEDGMENT STATEMENT It has been explained to me, , that the hysterectomy to be performed on me (RECIPIENT NAME) will make it impossible for me to become pregnant or bear children. I understand that a hysterectomy is a permanent operation. The reason for performing the hysterectomy and the discomforts, risks and benefits associated with the hysterectomy have been explained to me and all my questions have been answered to my satisfacti.

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Before submitting your request to modify OHC, please have the Medi-Cal beneficiary's Client Index Number (CIN) available and OHC information. The CIN is the first nine characters of the identification number located on the front of the beneficiary's Benefits Identification Card (BIC).

Bank Identification Number (BIN) and Processor Control Number (PCN): For submitting FFS claims to Medicaid via NCPDP D. 0, the BIN number is required in field 101-A1 and is "004740". The PCN (Processor Control Number) is required to be submitted in field 104-A4.

Enter the Member ID. This information may be obtained from the CBIC. Member IDs are assigned by NYS Medicaid and are composed of 8 characters in the format AANNNNNA, where A = alpha character and N = numeric character as shown in Exhibit 2.4. 2-2.

Each month in which you need Medicaid services, bring in, send or fax (if available in your county) your paid or unpaid medical bills to your local department of social services. Only send these bills when they are equal to or more than the amount of your excess income.

I understand that a hysterectomy (surgical removal of my uterus) is medically necessary and I have agreed to this operation. I acknowledge that I have been advised orally and in writing that the hysterectomy will cause me to be permanently incapable of reproducing (become sterile).

hysterectomy consent form may be a hospital form, a physician-designed form or a written. statement by the person who secures authorization. To be acceptable, however, the form. must include the following: • A statement that the procedure will render the patient permanently sterile and.

For more information, call the Medicaid Helpline at 1-888-692-6116 or visit the NYS website.

The member´s Medicaid MC Plan ID Card contains the Client Identification Number (CIN), which is unique to Medicaid members, and should be used to bill FFS. While in some cases the CIN may be embedded in the member's Medicaid MC Plan ID Number, it is always represented in this format: AA11111A.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232