Termination Of Pregnancy Form Step 1 of 4 25% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Date of Service* MM slash DD slash YYYY Name* First Last Error Message Provider InformationProvider NPI* 10 digitsProvider Name* Error Message Place of Service* Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Clinical InformationDiagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890 CPT Code(s) (Click + or - at the right to add up to 5 CPT Codes)*CPT CodeUnits Example CPT code: 12345Gestational Age (in weeks)*Please enter a number from 4 to 40. In accordance with Public Law 103-112, revision to the Hyde Amendment, the Rhode Island Department of Human Services (DHS) implemented the federal directive pertaining to Medicaid reimbursement for abortions. For dates of service on or after October 1, 1993, abortions may be performed for pregnancies resulting from rape, incest or as a result of life-threatening conditions of the mother. Reimbursement of abortions is based on the physician’s “Certification Statement” below that the abortion was performed to save the life of the mother, to terminate pregnancy resulting from rape or to terminate pregnancy resulting from incest. Listed below is the physician certification statement that must accompany all claims for abortions conducted for pregnancy resulting from rape or incest for federal compliance and proper reimbursement. A copy of the signed certification statement must be submitted with each claim or reimbursement to be considered. Physician signature must be original script, not typed or rubber-stamped. Please note that substitute wording will not be acceptable. Attach Clinical information* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician*Signature Date* Reason for Request* Rape or Incest Preservation of Mother’s life Rape or Incest* I Certify that on behalf of my professional judgment, the procedure performed, or that will be performed, was/is necessary to terminate a pregnancy that is a result of a rape or incest. I have counseled the recipient concerning the availability of health and social support services and the importance of reporting the rape to the appropriate enforcement authorities.Preservation of Mother’s life* I Certify that on behalf of my professional judgment, the procedure performed was/is necessary to save the life of the motherRequest Method* Standard Expedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited. Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Attach only PDF and Word filesSignature of Physician or Licensed Provider*Signature Date* CommentsAuthorization is not a guarantee of paymentCAPTCHA