Abortion certification form - Provider

Iowa Department of Human Services
Certification Regarding Abortion
www.amerihealthcaritasia.com
Certify to one of the following:
I certify that on the basis of my professional judgment:
❏ Life of the mother
___________________________________________________________________________________________________
(Name and address of the mother)
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 her in danger of death unless an abortion is performed.
❏Fetus deformed
The fetus carried by ___________________________________________________________________________________
(Name and address of the mother)
is physically deformed, mentally deficient or afflicted with a congenital illness based on:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
(Medical indications)
❏Incest
❏Rape
I, _____________________________________________,
I, _____________________________________________,
(Name of official)
of _____________________________________________
(Name of official)
of _____________________________________________
(Name of agency)
(Name of agency)
received a signed form from _________________________
received a signed form from _________________________
(Name and address of person reporting)
stating that ____________________________________
(Name and address of person reporting)
stating that ____________________________________
(Name and address of the mother)
was the victim of an incident of rape.
(Name and address of the mother)
was the victim of an incident of incest.
The incident took place on __________________________
The incident took place on __________________________
(Date)
and the incident was reported on _____________________.
(Date)
and the incident was reported on _____________________.
(Date)
The report included the name,
address and signature of the person making the report.
(Date)
The report included the name,
address and signature of the person making the report.
I further certify that the mother has been given the opportunity to view an ultrasound image of the fetus as part of the standard
care before an abortion is performed, and the mother has been provided information regarding the options relative to a pregnancy
including continuing the pregnancy to term and retaining parental rights following the child’s birth, continuing the pregnancy to
term and placing the child for adoption, and terminating the pregnancy.
Signature of attending provider:
_________________________________________ Date:_____________________
Signature of official of law enforcement, public or private health agency which may include a family physician:
___________________________________________________________ Date:_____________________
Iowa Department of Human Services Certification Regarding Abortion
Conditions for Medicaid payment for abortions
Legislation enacted by the Iowa General Assembly restricts payment for abortions through the Medicaid program to
the following situations:
1. The attending provider certifies in writing that continuing the pregnancy would endanger the life of the pregnant
woman. Federal funding is available in these situations only if 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.
2. The attending provider certifies in writing on the basis of the provider’s professional judgment that the fetus is
physically deformed, mentally deficient or afflicted with a congenital illness and states the medical indications for
determining the fetal condition.
3. The pregnancy is the result of rape; that incident was reported to a law enforcement agency or public or private
health agency, which may include a family physician, within 45 days of the date of the incident; and that report
contains the name, address and signature of the person making the report. An official of the agency must so
certify in writing.
4. The pregnancy is the result of incest; that incident was reported to a law enforcement agency or public or private
health agency, which may include a family physician, within 150 days of the incident; and that report contains
the name, address and signature of the person making the report. An official of the agency or physician must so
certify in writing.
A copy of the form “Certification Regarding Abortion” must be attached to any Medicaid claim associated with the
abortion. Payment will not be made to the attending provider or to other providers assisting in the abortion or to the
hospital if the required certification is not submitted by the provider with the claim for payment. It is the responsibility
of the attending provider to make a copy of the certification available to the hospital and other providers billing for the
services associated with the abortion.
In the case of pregnancy resulting from rape or incest, a certification from a law enforcement agency, public or
private health agency, or family physician is required as set forth above. The member, someone acting in her behalf
or the attending provider is responsible for obtaining the necessary certification from the agency involved. The form
“Certification Regarding Abortion” is to be used for this purpose. It is also the responsibility of the provider to make
a copy of the certification available to the hospital and any other provider billing for the service. This will facilitate
payment to the hospitals and other providers on abortion claims.
www.amerihealthcaritasia.com
ACIA-1522-196