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81243 form fillable 2026
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- Click ‘Get Form’ to open the 81243 form in the editor.
- In Part I, enter the patient's name and Medicaid number. Provide the diagnosis description and code, and include the physician's name and NPI number. Ensure the physician signs and dates this section before surgery.
- Move to Part II, where you will acknowledge receipt of information regarding the hysterectomy. Fill in the patient's name, date of birth, and representative's name if applicable. Both patient and representative must sign and date this section.
- In Part III, enter the date of surgery once it has been performed.
- For Part IV, if applicable, provide details about unusual circumstances surrounding the surgery. Include necessary medical records as required.
- Finally, ensure that Part V is completed by a state reviewer after submission for any unusual circumstances identified.
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