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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: _________________________

Document Information

Fact Name Description
Purpose This form is used by physicians to confirm early pregnancy loss and inform the patient about their rights regarding fetal death certification.
Patient Information The form requires the woman's name and the date of the positive pregnancy test to establish a clear record of the pregnancy.
Ultrasound Confirmation It includes a section to indicate whether the pregnancy was confirmed as intrauterine through ultrasound, which is critical for accurate medical documentation.
Miscarriage Options Patients can select from several options regarding the nature of the miscarriage, including negative tests or confirmed fetal loss, ensuring specificity in the medical record.
Physician's Role The form must be signed by the physician, affirming their professional assessment of the situation and the details provided.
State-Specific Registration In many states, there is an option to register fetal death, which requires submitting the form to the local Registrar of Vital Statistics.
Disposal of Fetal Remains The form outlines options for the disposal of fetal remains, including physician-assisted services, in accordance with state law.
No Charge for Cremation There is no fee for cremation without ashes, providing an accessible option for families during a difficult time.

Miscarriage Discharge Paper - Usage Guidelines

After completing the Miscarriage Discharge Paper form, it is important to submit it as directed. This form provides necessary documentation following a miscarriage and outlines options for fetal death registration and remains disposition.

  1. Begin by entering the woman's name in the first blank space provided.
  2. Fill in the date of the positive pregnancy test in the next blank space.
  3. Indicate whether the pregnancy was confirmed by an ultrasound by selecting "was" or "was not."
  4. In the next section, enter the date of the miscarriage.
  5. Select the appropriate option regarding the miscarriage from the provided choices:
    • 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.
  6. Print the physician's name in the designated area.
  7. Have the physician sign the form in the provided space.
  8. Enter the date of the physician's signature.
  9. Fill in the state where the fetal death occurred.
  10. Decide whether to register the fetal death and indicate your choice.
  11. If applicable, provide a signed and notarized document from the father if he is submitting the application.
  12. Choose whether you would like the physician to handle the disposal of the fetal remains by marking "Yes" or "No."
  13. Finally, have the mother sign and date the form in the designated areas.

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Dos and Don'ts

When filling out the Miscarriage Discharge Paper form, it is important to approach the process with care and attention. Here are some guidelines to consider:

  • Do ensure that all information is filled out completely and accurately. This includes the woman's name, dates, and relevant medical details.
  • Do consult with your healthcare provider if you have any questions about the form or the information required.
  • Do keep a copy of the completed form for your records. This can be important for future reference or if you need to discuss the matter with healthcare professionals.
  • Do understand your rights regarding the registration of fetal death and the options available for disposition of remains.
  • Don't leave any sections of the form blank unless instructed to do so. Incomplete forms may lead to delays or complications.
  • Don't hesitate to ask for assistance from a trusted friend or family member if you find the process overwhelming.

Common mistakes

  1. Incomplete Information: Failing to fill in all required fields can lead to delays or complications. Ensure that the woman’s name, dates, and physician's details are fully completed.

  2. Incorrect Selection: Choosing the wrong option regarding the nature of the miscarriage can cause legal and medical issues. Carefully read each option and select the one that accurately reflects the situation.

  3. Signature Issues: Not signing the form or having an illegible signature can invalidate the document. Make sure that the signature of the mother is clear and dated properly.

  4. Not Consulting with a Physician: Filling out the form without discussing it with a healthcare provider may lead to misunderstandings about the medical terminology and implications. Always consult with a physician to ensure accuracy.

  5. Ignoring State Regulations: Each state has different laws regarding fetal death registration. Failing to comply with local regulations can result in missed opportunities for legal registration. Research your state’s requirements.

  6. Overlooking Disposition Choices: Not indicating preferences for the disposal of fetal remains can create confusion later. Clearly state whether you want the physician to handle the remains and ensure that the disposition form is signed.

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