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Medicaid hysterectomy form 2026

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The document is a form (BHSF Form 96A) used by Louisiana's Medicaid Program to acknowledge that a recipient has received information regarding the implications of undergoing a hysterectomy, specifically that it will render her permanently incapable of reproduction. It outlines the conditions under which Medicaid will authorize payment for a medically indicated hysterectomy, requiring both oral and written acknowledgment from the individual and their representative before the procedure.

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Click ‘Get Form’ to open the Medicaid hysterectomy form in the editor.
Begin by entering the Recipient Name and MEDS Person No. in the designated fields. Ensure that this information is accurate as it identifies the individual receiving the procedure.
Next, fill in the Physician Name and Provider No. These details are crucial for processing and verifying the medical provider involved in the procedure.
Read through the acknowledgment statement carefully. This section informs you that a hysterectomy will render a woman permanently incapable of bearing children.
Sign and date the acknowledgment of receipt of information as the recipient. If applicable, have your representative sign and date as well. Ensure these signatures are completed prior to submitting your claim.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (159 Votes)
2006	4.4 Satisfied (304 Votes)

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