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Before I performed the hysterectomy on her I counseled her representative orally and in writing that the hysterectomy would render that individual permanently incapable of reproducing and the individual s representative has signed a written acknowledgment of receipt of the foregoing information. INSTRUCTIONS FOR COMPLETING THE HYSTERECTOMY ACKNOWLEDGMENT FORM CLAIMS FOR HYSTERECTOMY SERVICES WILL NOT BE PAID UNTIL THIS FORM IS COMPLETED IN FULL AND RECEIVED BY UTAH MEDICAID. ADDITIONAL...
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