<p> Division of Medical Services Certification Statement for Abortion</p><p>This form must be completed and signed by both the physician and the patient prior to the date of the abortion procedure. Medicaid does not cover abortions performed before the patient is determined to be Medicaid-eligible. This form must be attached to all claims for Medicaid payment. Please print your answers in the blanks provided.</p><p>SECTION I. TO BE COMPLETED BY PATIENT</p><p>Patient’s Name: ______Medicaid I.D. No.______(last, first, middle initial) Address: ______</p><p>Select one of the statements below which describes your situation:</p><p>A. ______Pregnancy resulted from forcibly compelled sexual intercourse (rape) </p><p>B. ______Pregnancy resulted from incest.</p><p>C. ______I was advised by my physician that this pregnancy will endanger my life if the fetus is carried to term. ______If pregnancy is a result of forcibly compelled sexual intercourse (rape) or incest, please provide the following requested information: 1. Date of incident ______(month, day, year) 2. I reported the incident to the following local law enforcement agency (specify):</p><p>______Date reported: ______(month, day, year) 3. I did not report the incident (explain):</p><p>______</p><p>______</p><p>I certify that the above information is true. I understand all medical records relating to this abortion must be provided to representatives of the Arkansas Medicaid Program upon request.</p><p>______Date: ______Patient’s signature or parent’s or guardian’s signature </p><p>SECTION II. TO BE COMPLETED BY THE PHYSICIAN</p><p>A. I certify that the patient:</p><p>______is less than 14 years of age. _____ is physically unable to communicate.</p><p>______is mentally defective or mentally incapacitated.</p><p>B. I was advised by the patient that:</p><p>______this pregnancy is a result of forcibly compelled sexual intercourse as defined in Ark Code Ann § 5-14-103. ______this pregnancy is a result of incest as defined in Ark Code Ann § 5-26-202.</p><p>______this pregnancy would endanger the life of the mother if the fetus were carried to term. </p><p>Physician’s signature: ______Date: ______</p><p>Performing physician’s signature (if different) ______Date: ______</p><p>Performing physician’s Provider ID Number/Taxonomy Code: ______</p><p>Address: ______</p><p>DMS-2698 (Rev. 4/07)</p>