Do you have to file Form Ldss 3113 when you make taxable distributions from an IRA or other qualified retirement plan? What is the Form Ldss 3113 used for? How do you complete it? This article will provide an overview of the Form Ldss 3113 and answer these questions. The article will also explain when you don't have to file the form. When it comes to withdrawing money from your retirement account, there are a few things you need to know about Form Ldss 3113. This form is used to report distributions that are subject to federal income tax withholding. It's important to understand when you're required to file this form so that you can avoid any penalties. In this article, we'll provide an overview of the Form Ldss 3113 and answer some common questions about it. We'll also discuss when you're not required to file the form.
| Question | Answer |
|---|---|
| Form Name | Form Ldss 3113 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ldss 3113 form, RECIPIENTS, secondarily, anesthesiologist |
ACKNOWLEDGEMENT OF HYSTERECTOMY INFORMATION
(NYS MEDICAID PROGRAM)
EITHER PART I OR PART II MUST BE COMPLETED
RECIPIENT ID NO.
SURGEON’S NAME
PART I: RECIPIENT’S ACKNOWLEDGMENT STATEMENT AND SURGEON’S CERTIFICATION
RECIPIENT’S ACKNOWLEDGMENT STATEMENT
It has been explained to me, |
|
, that the hysterectomy to be performed on me |
(RECIPIENT NAME)
will make it impossible for me to become pregnant or bear children. I understand that a hysterectomy is a permanent operation. The reason for performing the hysterectomy and the discomforts, risks and benefits associated with the hysterectomy have been explained to me and all my questions have been answered to my satisfaction prior to the surgery.
RECIPIENT OR REPRESENTATIVE SIGNATURE
X
DATE
INTERPRETER’S SIGNATURE (If required)
X
DATE
SURGEON’S CERTIFICATION
The hysterectomy to be performed for the above mentioned recipient is solely for medical indications. The hysterectomy is not primarily or secondarily for family planning reasons, that is, for rendering the recipient permanently incapable of reproducing.
SURGEON’S SIGNATURE
DATE
X
PART II: WAIVER OF ACKNOWLEDGMENT AND SURGEON’S CERTIFICATION
The hysterectomy performed on |
|
was solely for medical indications. |
(RECIPIENT NAME)
The hysterectomy was not primarily or secondarily for family planning reasons, that is, for rendering the recipient permanently incapable of reproducing. I did not obtain Acknowledgement of Receipt of Hysterectomy information from her and have her complete Part I of this form because (please check the appropriate statement and describe the circumstances where indicated):
1.She was sterile prior to the hysterectomy. (briefly describe the cause of sterility)
2.The hysterectomy was performed in a life threatening emergency in which prior acknowledgment was not possible. (briefly describe the nature of the emergency)
______________________________________________________________________________
3. She was not a Medicaid recipient at the time the hysterectomy was performed but I did inform her prior to surgery that the procedure would make her permanently incapable of reproducing.
SURGEON’S SIGNATURE
DATE
X
DISTRIBUTION: File patient’s medical record; hospital submit with claim for payment; surgeon and anesthesiologist submit with claims for payment; patient.