Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the document online and open it for editing.
2. In Part I, enter the patient’s name and 13-digit Medicaid number, provide the diagnosis requiring the hysterectomy, and include the diagnosis code. If applicable, list the name of any representative.
3. Enter the name and NPI number of the physician performing the procedure. The physician must sign and date this section; ensure the date precedes the surgery date to prevent denial.
4. In Part II, the patient (or representative) acknowledges their understanding of the procedure by filling in their name, date of birth, and signing below. Again, if a representative is signing, mark N/A where appropriate.
5. Part III requires the physician to enter the date the surgery was performed after it has taken place.
6. Part IV should be filled out in cases of unusual circumstances such as prior sterility or life-threatening situations. Include the name of the patient and physician, check the relevant circumstance, and confirm if the patient was informed about the permanence of reproduction capabilities post-surgery.
7. In Part V, the reviewer at the state will complete this section when there are unusual circumstances. Physically submit the completed form according to the guidelines provided, ensuring all necessary medical records are attached.

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