Content Overview
File Details
| Fact Name | Description |
|---|---|
| Purpose of the Form | This form is used by physicians to confirm early pregnancy loss and inform the patient of their rights regarding fetal death certification. |
| Patient Information | The form requires the woman's name and the date of the positive pregnancy test to document the pregnancy history. |
| Ultrasound Confirmation | It includes an option to indicate whether the pregnancy was confirmed as intrauterine by an ultrasound. |
| Miscarriage Options | The form provides several options for the physician to select regarding the nature of the miscarriage, including negative pregnancy tests and confirmed miscarriages. |
| State-Specific Registration | In certain states, the form advises that parents can register their fetal death with local Vital Statistics, subject to state laws. |
| Father's Role | If the father submits the application for fetal death registration, he must provide a notarized statement from the mother confirming she provided him with a copy of the form. |
| Disposition of Remains | The mother has the option to have the physician handle the disposal of fetal remains, in accordance with state law. |
| Cost of Services | There is no charge for the physician to perform cremation without ashes for the fetal remains, should that option be chosen. |
Sample - Miscarriage Discharge Paper Form
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: _________________________
Common mistakes
Filling out the Miscarriage Discharge Paper form can be an emotionally challenging task. However, it is essential to do it correctly to ensure proper documentation and access to necessary services. One common mistake people make is leaving the woman’s name blank. This section is crucial as it identifies the individual involved. Omitting this information can lead to delays and complications in processing the document.
Another frequent error occurs when individuals fail to provide the correct date of the positive pregnancy test. This date is significant for medical records and future references. If this information is inaccurate or missing, it may hinder the ability to track the pregnancy timeline and any related medical care.
Choosing the wrong option regarding the type of miscarriage is also a notable mistake. The form offers specific choices, and selecting the incorrect one can lead to misunderstandings about the circumstances surrounding the pregnancy loss. Carefully reviewing the options and ensuring the correct selection will help avoid unnecessary confusion.
Many people overlook the need for the physician's printed name and signature. This section validates the document and confirms that a medical professional has reviewed and approved the information. Without these signatures, the form may be deemed invalid, preventing access to important services.
Additionally, failing to indicate whether the physician should handle the disposal of fetal remains can create complications. This choice should be clearly marked. Not specifying this preference may lead to uncertainty about the next steps in the process, causing additional stress during an already difficult time.
Finally, neglecting to sign and date the form can render it incomplete. This final step is critical for ensuring that the document is legally binding. Without a signature, the form may not be accepted by the local Registrar of Vital Statistics, which could delay the registration of fetal death and the related services.
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