Get Ne Hhs-11 2011-2025

The NE HHS-11 form is essential for reporting induced abortions in Nebraska. This comprehensive guide provides clear, step-by-step instructions to ensure that you can accurately complete the form online with ease.

Follow the steps to successfully complete the NE HHS-11 form online.

1. Press the ‘Get Form’ button to access the form and open it in the online editor.
2. Identify the name of the facility where the abortion was performed and provide the complete facility address, including city and state.
3. Enter the date the abortion was performed, ensuring to input the month and year accurately.
4. Provide the facility chart case number for tracking purposes, as required.
5. Indicate the patient's legal residence, specifying the state and county.
6. Record the patient's age at their last birthday.
7. Select the patient's marital status from the provided options.
8. Check the appropriate race and specify ancestry if required.
9. Indicate the highest level of education the patient has completed by checking the corresponding box.
10. Answer whether a determination of probable postfertilization age was made, choosing 'Yes' or 'No'.
11. If you answered 'Yes' to the previous question, specify the probable age in weeks and the method used for determination.
12. If 'No' was selected in step 10, indicate whether a medical emergency existed and provide additional details if applicable.
13. Complete section 12 by indicating if the postfertilization age was twenty weeks or more and if an abortion was necessary to preserve the mother's health.
14. Choose the method of abortion used to terminate the pregnancy.
15. If applicable, confirm if the method used was the best opportunity for the unborn child to survive.
16. Provide necessary details regarding the basis of medical judgments if standard procedures were not followed.
17. Complete the sections related to previous pregnancies and indicate any complications experienced.
18. Provide clinical estimates of gestation and detail the length and weight of the fetus.
19. Document the reasons for the abortion and any associated complications.
20. Finally, fill in the name of the attending physician, the initials of the staff person completing the report, and obtain the attending physician's signature.
21. Once all sections are filled and reviewed for accuracy, you can save your changes, download, or print the completed form for submission.

Take action now and complete your NE HHS-11 form online to ensure proper documentation.