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Pennsylvania physician certification form 2026

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The document is a physician certification form for abortion services, requiring details about the patient and the circumstances necessitating the procedure. It includes two parts: one for cases where an abortion is needed to prevent death due to medical conditions, and another for cases involving rape or incest, which requires additional documentation. The form emphasizes confidentiality and mandates physician signatures and contact information.

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Click ‘Get Form’ to open the Pennsylvania Physician Certification Form in our platform.
Begin by entering the patient’s MA number at the top of the form. Ensure that a copy is attached to all invoices for abortion services.
Fill in the date, followed by the patient’s name and birth date. Accurate information is crucial for proper documentation.
Complete the patient’s address, ensuring all details are correct for future correspondence.
Choose either Part I or Part II based on the patient's situation. For Part I, certify that an abortion is necessary to avert death by providing your professional judgment.
In Part II, if applicable, indicate if the patient is a victim of rape or incest and check the appropriate box. Attach a Recipient Statement Form as required.
Sign and date the form at the designated areas, including your street address and phone number for verification purposes.

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What is a PA IEB?

Welcome to the PA Independent Enrollment Broker (PA IEB) The PA IEB is a contracted statewide entity facilitating the enrollment process for Pennsylvania residents seeking home and community based services and supports as well as long term services and supports.

What is a PA 4 form for Medicaid?

The PA-4 form will be used to assist the assessor in determining whether home and community based long-term care services can best meet the needs of the individual. Complete the top portion of the PA-4 with the individuals name, address, phone number, date of birth, veteran status, Social Security and Medicaid number.

What is the phone number for PA IEB?

Call the PA Independent Enrollment Broker (PA IEB) at 1-877-550-4227. Learn more about Home and Community Based Waiver Services. Tell PA IEB you want to apply for waiver services and schedule your first in-home visit. Read the list of papers you need for the first in-home visit.

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What is the PA IEB program?

The Independent Enrollment Broker is a contracted statewide entity to facilitate and streamline the eligibility/enrollment process for applicants seeking services for several Pennsylvania waivers/programs.

What is the PA waiver program?

Waiver Information The name waiver comes from the fact that the federal government waives Medical Assistance/Medicaid rules for institutional care in order for Pennsylvania to use the same funds to provide supports and services for people closer to home in their own communities.

What is Maximus from PA?

Maximus PA Independent Enrollment Broker program assists people with disabilities apply for home and community-based programs in southcentral PA.