CERTIFICATION OF MEDICAL NECESSITY FOR ABORTION

Updated: January 1, 2015
INSTRUCTIONS FOR COMPLETING
"CERTIFICATION OF MEDICAL NECESSITY FOR ABORTION"
1.
Date of Service: The date the abortion was performed. This can be typed or
handwritten.
2.
Individual's Full Name: The name of the individual can be typed or handwritten.
3.
Individual's Date of Birth: Individual’s date of birth can be typed or handwritten.
4.
Individual’s Address: Individual’s complete address including street, city, state,
and zip code. This can be typed or handwritten.
5.
Condition: Mark the block indicating the applicable reason for the abortion. This
can be typed or handwritten.
6.
Supporting Documentation: Mark the block that applies to the type of supporting
documentation. This can be typed or handwritten.
7.
Physician NPI# and Address: The physician's NPI# and complete address
including street, city, state, and zip code. This can be typed or handwritten.
8.
Physician Signature/Date: The physician must sign his/her name and date
simultaneously in his/her own handwriting after the procedure.
Updated: January 1, 2015
CERTIFICATION OF MEDICAL NECESSITY FOR ABORTION
DATE OF SERVICE:
1
Based on my professional judgment, I certify that an abortion is medically necessary in
the case of:
Individual’s Full Name:
______2__________________________________________
Individual’s Date of Birth: ______3__________________________________________
Individual’s Address:
4
Street Address
City
State
Zip Code
for the following reason:
(CHECK ONE)
5
 There is credible evidence to believe the pregnancy is the result of rape or incest.
 The
abortion is medically necessary as the woman suffers from a physical
disorder, physical injury, or physical illness, including a life endangering physical
condition caused by or arising from the pregnancy itself that would place the
woman in danger of death unless an abortion is performed.
SUPPORTING DOCUMENTATION:
6
(PLEASE CHECK THOSE THAT APPLY AND ATTACH DOCUMENTS)
 Documentation from a law enforcement agency indicating the patient has made a
credible report as the victim of incest or rape.
 Documentation from a public health agency, Department of Human Services or
Counseling agency (such as a Rape Crisis Center) indicating the patient has
made a credible report as the victim of incest or rape.
 Medical records documenting the life saving nature of the abortion.
 Other (Please Specify):
PHYSICIAN PERFORMING ABORTION:
Physician NPI#:
Physician Address:
Physician Signature:
_____________7___________________________________
_________________________________________________
8
Date:
Updated: January 1, 2015
CERTIFICATION OF MEDICAL NECESSITY FOR ABORTION
DATE OF SERVICE:
Based on my professional judgment, I certify that an abortion is medically necessary in
the case of:
Individual’s Full Name:
________________________________________________
Individual’s Date of Birth: ________________________________________________
Individual’s Address:
Street Address
City
State
Zip Code
for the following reason:
(CHECK ONE)
 There is credible evidence to believe the pregnancy is the result of rape or incest.
 The
abortion is medically necessary as the woman suffers from a physical
disorder, physical injury, or physical illness, including a life endangering physical
condition caused by or arising from the pregnancy itself that would place the
woman in danger of death unless an abortion is performed.
SUPPORTING DOCUMENTATION:
(PLEASE CHECK THOSE THAT APPLY AND ATTACH DOCUMENTS)
 Documentation from a law enforcement agency indicating the patient has made a
credible report as the victim of incest or rape.
 Documentation from a public health agency, Department of Human Services or
Counseling agency (such as a Rape Crisis Center) indicating the patient has
made a credible report as the victim of incest or rape.
 Medical records documenting the life saving nature of the abortion.
 Other (Please Specify):
PHYSICIAN PERFORMING ABORTION:
Physician NPI#:
Physician Address:
Physician Signature:
__________________________________________________
__________________________________________________
__________________________________________________
Date:
Updated: January 1, 2015
CERTIFICADO DE NECESIDAD DE ABORTO
FECHA DEL SERVICIO: _________1__________
Basado en mi opinión profesional, certifico que un aborto es médicamente necesario en
el caso de:
Nombre Completo del Individual: _____________2_____________________________
Fecha de Nacimiento de Individual: ____________3____________________________
Direccion del Individual:
4
Dirección de su residencia
Ciudad
Estado
Código Postal
Por la siguiente razón:
(MARQUE UNA)
5
 Hay suficiente evidencia para creer que el embarazo es el resultado de violación
o incesto.
 El aborto es médicamente necesario ya que la mujer sufre de un desorden físico,
daño físico o enfermedad física, incluyendo una condición que pone en peligro
su vida causada o desarrollada por el embarazo mismo que pondría a la mujer
en peligro de muerte al menos que el aborto se efectué.
DOCUMENTACION DE APOYO:
6
(POR FAVOR MARQUE
DOCUMENTOS)
TODOS
LOS
QUE
APLICAN
Y
ANEXE
LOS
 Documentación de una agencia que ejecute
la ley indicando que el paciente a
hecho una denuncia creíble como una victima de violación o incesto.
 Documentación
de una agencia de salud social, El Departamento de Servicios
Humanos (DHS) o una agencia de concejeria (como el Centro de Crisis para
Mujeres Violadas) indicando que el paciente hizo una denuncia creíble como una
victima de violación o incesto.
 Historial médico que documente la razón del aborto como una de salvación de la
vida de la mujer.
 Otro (Favor de especificar):
CIRUJANO QUE HARA EL ABORTO:
NPI# del Médico:
Direccion del Médico:
Firma del Médico:
______________7___________________________________
__________________________________________________
__________________________________________________
8
Fecha: