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Miscarriage Discharge Paper Sample

FORM FOR USE BY PHYSICIANS IN AN OFFICE SETTING

EARLY PREGNANCY LOSS

CONFIRMATION OF MISCARRIAGE AND NOTICE OF RIGHT TO FETAL DEATH

CERTIFICATE

This is to certify that _____________________ (woman’s name) had a positive pregnancy test

on ______ (date).

This (was/ was not) confirmed as an intrauterine pregnancy by an ultrasound.

On ______ (date) ___________ (woman’s name):

Select appropriate option:

•Had a negative pregnancy test signifying a miscarriage, ectopic pregnancy, false pregnancy test, blighted ovum, etc. No fetus was ever confirmed or visualized.

•Had a miscarriage of fetal products of conception (placenta, bleeding, etc) confirmed by dropping Beta HCG hormone test. The miscarriage was not, to the best of my knowledge, the result of the purposeful termination of a pregnancy.

•Had a miscarriage of a ___________week fetus/infant that was delivered with no sign of life. The miscarriage was not the result of the purposeful termination of a pregnancy.

Physician Printed Name: ____________________________

Physician Signature: ____________________________ Date: ____________

In the state of __________, you have the option to register your fetal death. If you want to

exercise this option, you must submit this written statement to the local Registrar of Vital Statistics in the district where the fetal death occurred. If the father submits the application, he must also include with this statement a signed and notarized document from you attesting that you voluntarily provided the father with a copy of this statement.

You can use the fetal death certificate to arrange private funeral services and burial. You may also choose to have the physician dispose of the fetal remains in accordance with _________

state law. There is no charge for this service of cremation without ashes. You will need to sign the disposition form designating your choice of disposition of the remains.

Would you like the physician to handle disposal of the fetal remains if fetal remains can be identified. Yes  No 

Signature of Mother: _______________________ Date: _________________________

⇓ PDF File

Instructions on Utilizing Miscarriage Discharge Paper

After obtaining the Miscarriage Discharge Paper form, it’s important to fill it out accurately to ensure all necessary information is documented correctly. This form will be used for medical and legal purposes, so taking your time to complete it is essential.

  1. Begin by entering the woman’s full name in the designated space for her name.
  2. Fill in the date of the positive pregnancy test in the provided area.
  3. Indicate whether the pregnancy was confirmed as an intrauterine pregnancy by ultrasound by selecting the appropriate option.
  4. On the specified date, choose the correct option that describes the miscarriage situation. Options include:
    • Had a negative pregnancy test signifying a miscarriage, ectopic pregnancy, false pregnancy test, blighted ovum, etc. No fetus was ever confirmed or visualized.
    • Had a miscarriage of fetal products of conception (placenta, bleeding, etc.) confirmed by dropping Beta HCG hormone test. The miscarriage was not, to the best of my knowledge, the result of the purposeful termination of a pregnancy.
    • Had a miscarriage of a ___________ week fetus/infant that was delivered with no sign of life. The miscarriage was not the result of the purposeful termination of a pregnancy.
  5. Print the physician’s name clearly in the section labeled “Physician Printed Name.”
  6. Have the physician sign the form in the “Physician Signature” area.
  7. Enter the date of the physician’s signature in the corresponding space.
  8. Fill in the state where the fetal death occurred in the designated area.
  9. Decide if you would like to register the fetal death. If yes, note that you will need to submit the statement to the local Registrar of Vital Statistics.
  10. If the father is submitting the application, ensure that he includes a signed and notarized document from you, confirming he has a copy of this statement.
  11. Indicate whether you would like the physician to handle the disposal of the fetal remains by checking “Yes” or “No.”
  12. Finally, sign and date the form in the designated areas for the mother’s signature and date.

Once the form is completed, keep a copy for your records. You may need to submit this form to the appropriate authorities or keep it for personal documentation. If you have any questions or need assistance, don’t hesitate to reach out for help.

Misconceptions

Misconceptions about the Miscarriage Discharge Paper form can lead to confusion and unnecessary stress during a difficult time. Here are some common misunderstandings:

  • It is only for confirmed miscarriages. Many believe the form is only applicable after a miscarriage has been confirmed. However, it can also be used in cases of negative pregnancy tests or ectopic pregnancies.
  • Only physicians can fill it out. While a physician must sign the form, the information can be provided by the patient or a healthcare provider assisting with the process.
  • The form is mandatory in all states. Some think that this form is required everywhere. In reality, the requirements for documentation can vary by state.
  • It is only for women who have had a surgical procedure. This form applies to any type of early pregnancy loss, not just those that involve surgery or medical intervention.
  • Filing the form means you must register the fetal death. While the form provides the option to register a fetal death, it is not mandatory. Families can choose whether to pursue this option.
  • There is a fee for using the form. Many people think that there are costs associated with completing the form. However, there is no charge for the service of cremation without ashes if chosen.
  • The form is only for women. Some believe that only the mother can handle the paperwork. In some cases, the father can also submit the application with the proper documentation.
  • It must be filled out immediately after the loss. There is no strict timeline for when this form must be completed. Families can take the time they need to process their loss.
  • Once signed, the decision is final. Some think that signing the form locks them into a specific choice for the disposition of remains. In fact, families can change their minds about how they wish to proceed.

Documents used along the form

The process following a miscarriage can be emotionally and legally complex. Various forms and documents play a crucial role in ensuring that the necessary procedures are followed. Understanding these documents can help individuals navigate this difficult time more effectively.

  • Fetal Death Certificate: This document officially records the death of a fetus. It is essential for legal purposes and may be required for burial or cremation services. Parents can request this certificate from the physician who confirmed the miscarriage.
  • Disposition Form: This form allows parents to specify how they wish to handle the remains of the fetus. Options may include burial, cremation, or other methods in accordance with state laws. Signing this document is crucial for ensuring that the parents' wishes are honored.
  • Medical Records Release Form: This form enables parents to obtain copies of their medical records related to the miscarriage. Access to these records can be important for future medical care or for personal records.
  • Virginia Motor Vehicle Bill of Sale: If you are looking to buy or sell a vehicle in Virginia, a blank form is here a blank form is here to assist you in this process.
  • Authorization for Autopsy: If parents wish to have an autopsy performed on the fetus, this document grants permission for medical professionals to conduct the examination. This may provide answers regarding the cause of the miscarriage.
  • Grief Support Resources: While not a formal document, this resource list can provide parents with information about counseling services and support groups. Emotional support is vital during this challenging time.

Each of these documents serves a specific purpose and can significantly impact the experience of parents dealing with a miscarriage. It is important to understand and complete these forms to ensure that all legal and personal preferences are respected.