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Get UT Abortion Acknowledgment And Certification Form 2012-2024

Medicaid ID Number Date of Service Recipient Address City State Zip Code Country Instructions: Part I and III or IIb and III must be completed and the ATTENDING physician performing the procedure must sign below. Part IIa and IV must be completed by the Medicaid recipient or their legal representative. Completion of this form is required of physicians performing induced abortio.

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