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In Florida, the Abortion Certification Form plays a crucial role in the process surrounding abortion services. This form is designed to ensure that the medical and legal requirements are met before a procedure can be performed. It requires the recipient's name and address, along with their Medicaid identification number, establishing a clear connection to the individual receiving care. The physician completing the form must provide their name, signature, and Medicaid provider number, confirming their professional involvement in the procedure. Additionally, the form includes a section where the physician must articulate the specific medical reasons for the abortion, which may include serious health risks to the woman or circumstances such as rape or incest. This documentation is vital not only for compliance with state regulations but also for securing Medicaid reimbursement. The integrity of the information provided is emphasized, as any discrepancies in the medical records could lead to recoupment of funds. Understanding this form is essential for both healthcare providers and patients navigating the complexities of abortion services in Florida.
Form Example
STATE OF FLORIDA
ABORTION
CERTIFICATION FORM
SECTION I
1.Recipient’s Name:___________________________________________________________________
2.Address:___________________________________________________________________________
3.Medicaid Identification Number________________________________________________________
SECTION II
4.On the basis of my professional judgement, I have performed an abortion on the above named recipient for the following reason:
The woman suffers from a physical disorder, physical injury, or physical illness, including a life- endangering physical condition caused or arising from the pregnancy itself that would place the woman in danger of death unless an abortion is performed.
Based on all the information available to me, I concluded that this pregnancy was the result of an act of rape.
Based on all the information available to me, I concluded that this pregnancy was the result of an act of incest.
I have documented in the recipient’s medical record the reason for performing the abortion; and I understand that Medicaid reimbursement to me for this abortion is subject to recoupment if medical record documentation does not reflect the reason for the abortion as checked above.
5. |
___________________________________ |
6. _____________________________________ |
|
Physician’s Name |
Physician’s Signature |
7. |
___________________________________ |
8. _____________________________________ |
|
Physician’s Provider Number |
Date of Signature |
AHCA MedServ Form 011, (JUN 2016), incorporated by reference in Rule
Document Breakdown
| Fact Name | Detail |
|---|---|
| Form Title | Abortion Certification Form |
| Governing Law | Florida Statutes, Chapter 390 |
| Recipient Information | Includes name, address, and Medicaid identification number |
| Reason for Abortion | Must be documented based on physical disorder, rape, or incest |
| Physician's Responsibility | Must provide professional judgment and document the reason in the medical record |
| Medicaid Reimbursement | Subject to recoupment if documentation does not match the stated reason |
| Signature Requirement | Physician must sign and provide their Medicaid provider number |
| Form Date | Last updated in August 2001 |
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