AHCA MedServ Form 011 at a glance
What it is: AHCA MedServ Form 011 is the State of Florida Abortion Certification Form.
Who signs: In Box 4, mark the reason for the abortion. On the basis of your professional judgement, you have performed an abortion on the named recipient for this 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. Or, based on all the information available to you, you concluded that this pregnancy was the result of an act of rape. Or, based on all the information available to you, you concluded that this pregnancy was the result of an act of incest. You have documented in the recipient's medical record the reason for performing the abortion, and you understand that Medicaid reimbursement to you for this abortion is subject to recoupment if medical record documentation does not reflect the reason for the abortion as checked in Box 4. Then enter the Physician's Name in Box 5, sign as the Physician's Signature in Box 6, and enter the Physician's Provider Number in Box 7 and the Date of Signature in Box 8.
A filled-in AHCA MedServ Form 011 example: a physician certifies the reason
How to fill out AHCA MedServ Form 011, box by box
Boxes 1 to 3, the recipient
Enter the recipient's Name in Box 1, the Address in Box 2 and the Medicaid Identification Number in Box 3.
Box 4, the reason for the abortion
Sources
[1] AHCA MedServ Form 011 (JUN 2016), State of Florida Abortion Certification Form (the Official source link on this page).