Abortion Paperwork Florida Form PDF Details

In Florida, the procedure for obtaining an abortion involves several regulatory steps, one of which includes the completion of the Abortion Certification Form. This document serves a pivotal role in the administration of abortion services within the state, specifically for those seeking Medicaid assistance for the procedure. It requires the providing physician to record critical information about the patient, including name, address, and Medicaid Identification Number. Moreover, it necessitates a comprehensive account from the physician regarding the reason for the procedure, which must fall within the narrow exceptions allowed under the state’s funding restrictions—namely, if the pregnancy poses a significant risk to the woman’s life, or if the pregnancy resulted from an act of rape or incest. The form also mandates that the physician document this rationale in the patient's medical records as a prerequisite for Medicaid reimbursement. In addition to the core information, the form collects the physician's name, signature, Medicaid Provider Number, and the date of signature, ensuring accountability and adherence to these stipulations. Its design reflects the intricate balance sought between access to abortion services under specified conditions and the regulatory framework governing such access in Florida, particularly concerning Medicaid-funded abortions. August 2001 marks the form's issuance, symbolizing a specific moment in the evolving landscape of abortion legislation within the state.

QuestionAnswer
Form NameAbortion Paperwork Florida Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesreal abortion discharge papers, abortion papers, get the real abortion discharge papers florida form, florida paperwork to file show cause order form

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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 judgment, 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 patient’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 Medicaid Provider Number

Date of Signature

August 2001

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Date of Signature, AHCA MedServ Form JUN , and record documentation does not of fl abortion form

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