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Get How To Fill Out Form Ldss 3113

TATEMENT AND SURGEON S CERTIFICATION RECIPIENT S ACKNOWLEDGMENT STATEMENT It has been explained to me, , that the hysterectomy to be performed on me (RECIPIENT NAME) will make it impossible for me to become pregnant or bear children. I understand that a hysterectomy is a permanent operation. The reason for performing the hysterectomy and the discomforts, risks and benefits associated with the hysterectomy have been explained to me and all my questions have been answered to my satisfacti.

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  • Certification
  • Acknowledgement
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  • Anesthesiologist
  • Hysterectomy
  • medicaid
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  • rendering
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