F-1161 - Abortion Certification Statements (Page 2 of 2) in pdf

F-1161 - Abortion Certification Statements Page 2

ABORTION CERTIFICATION STATEMENTS

Page 2 of 2

F-1161 (10/08)

SECTION II — VICTIM OF SEXUAL ASSAULT OR INCEST

I, ___________________________________________________________________________ , certify that it is my belief that

(Name — Provider)

__________________________________________________________________________________________________, of

(Name — Member)

__________________________________________________________________ , was the victim of sexual assault or incest.

(Address — Member)

___________________________________________________________________ _____________________

SIGNATURE — Physician

Date Signed

SECTION III — GRAVE AND LONG-LASTING DAMAGE TO PHYSICAL HEALTH

I, _________________________________________________________________________________ , certify on the basis of

(Name — Provider)

my best clinical judgment that due to an existing medical condition, grave, long-lasting physical health damage to

__________________________________________________________________________________________________, of

(Name — Member)

____________________________________________________________________________________________________,

(Address — Member)

would result if the pregnancy were carried to term. The following medical condition necessitates the abortion (specify the

medical condition / diagnosis):

____________________________________________________________________________________________________

___________________________________________________________________ _____________________

SIGNATURE — Physician

Date Signed

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