Ohio Department of 0HGLFDLG ABORTION CERTIFICATION FORM ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the appropriate reason for the abortion from the options provided. Check only one box that best describes the situation.
3. Fill in the Patient’s Name in the designated field, ensuring accuracy for proper identification.
4. Enter the Patient’s Address, including City, State, and Zip Code to ensure correct documentation.
5. Provide the Patient’s Medicaid Billing Number in the specified section for reimbursement purposes.
6. Next, type in the Physician’s Name and their Medicaid/NPI Provider Number to validate medical authority.
7. The Physician must sign and date the form at the bottom to complete it. Ensure all fields are filled out correctly before submission.

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