Form MAP-235, Certification Form for Induced Miscarriage

What is Form MAP 235?

The MAP-235 is also known as the Certification Form for Induced Abortion or Induced Miscarriage. MAP-235 is a Kentucky Medicaid physician certification form. It can be used by medical specialists only. This is the legal document that is operated and recorded by the government authority. The form is active on the territory of the state. If you are from another state and you use the help of specialists not from Kentucky, you need to fill out another form. The statement can be provided only by the doctor and can’t be filled in by the patient. It will not be verified without the doctor’s signature. The document must state that without abortion the patient’s life is in danger. Enter the procedure performed and its actual date.

A physician who uses the template has to provide the license number.

What I need the Form MAP 235 for?

• You can find physical disorder, injury, or any illness that is a death threat to the woman while she carries a fetus. This diagnosis has to be confirmed;

• It supports Kentucky Medicaid claims for an induced abortion or induced miscarriage in the limited circumstances the form lists.

• The patient may ask for the template from the doctor as well. You have to send a copy to the patient if it is required.

How to fill out Form MAP 235?

The official form is available at https://www.chfs.ky.gov/agencies/dms/MAPForms/MAP235.pdf. It is also available on the Internet. There you can read it and also download it on your device. If you want to fill it out online you need to search for a program that works with PDF documents. One of the most obvious choices is PDFLiner which contains all the tools you need and even helps you to create your own electronic signature which you can later use for all the documents you provide. Apart from that, you can add extra sections if you need. Once you fill it, save the document on your device. Submit with the applicable claim according to the payer's instructions. The printable version is available for you. Here is what you need to include inside:

• Provide your name and the name of your patient. Share the address of the patient;

• Decide the type of disorder and put a tick in the appropriate box that matches the patient’s condition;

• Enter the procedure performed and its actual date;

• Put your signature and name. Include your license number there.

Organizations that work with Form MAP 235

• Kentucky Cabinet for Health and Family Services, Department for Medicaid Services;

• Hospitals and private doctors within the state.