Get Ut Abortion Acknowledgment And Certification Form 2012-2025
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How to fill out the UT Abortion Acknowledgment And Certification Form online
Completing the UT Abortion Acknowledgment And Certification Form is an essential step for the reimbursement process for abortion services under Medicaid. This guide will provide you with clear, step-by-step instructions to ensure that you fill out the form accurately and efficiently, whether you are doing so online or through another method.
Follow the steps to complete the form online
- Press the ‘Get Form’ button to access the UT Abortion Acknowledgment And Certification Form and open it in your document editor.
- Start by filling out the recipient demographics section. Provide the recipient's full name, Medicaid ID number, date of service, and complete address including country.
- Complete Section I if the mother’s life is in danger. The physician must provide their professional opinion regarding the life-threatening condition and describe it clearly.
- If applicable, Section II must be completed by both the recipient (or their legal representative) and the physician. Ensure to certify whether the pregnancy resulted from rape or incest.
- In Section III, the attending physician must certify that they will retain records to support the certification and that Medicaid funds will not be used to reimburse abortions except under specified circumstances.
- Section IV requires the recipient (or their legal representative) to certify that the provided information is true and accurate by signing and dating the form.
- If applicable, complete Section V to waive the consent form requirement for the induction of fetal demise. This section should be filled out by the physician.
- After completing all relevant sections, ensure all signatures are obtained and then you can save changes, download, print, or share the form as needed.
Fill out the UT Abortion Acknowledgment And Certification Form online today to ensure timely processing and reimbursement.
Utah Medicaid covers abortions under specific circumstances, primarily when the mother's health is at risk or in cases of rape or incest. If you are considering this option, it is important to understand the necessary qualifications and documentation. Proper forms, like the UT Abortion Acknowledgment And Certification Form, ensure you meet state requirements while accessing health services.
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