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Content Overview

Guide to Writing Miscarriage Discharge Paper

Completing the Miscarriage Discharge Paper form is a necessary step following a miscarriage. This form serves multiple purposes, including documenting the event and providing options for the next steps regarding fetal remains. Below are the steps to fill out the form accurately.

  1. Begin by entering the woman’s full name in the designated space.
  2. Fill in the date of the positive pregnancy test.
  3. Indicate whether the pregnancy was confirmed as an intrauterine pregnancy by ultrasound.
  4. On the specified date, choose the appropriate option that describes the miscarriage. Select one of the following:
    • 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 in the provided space.
  6. Obtain the physician's signature and date it accordingly.
  7. Specify the state where the miscarriage occurred.
  8. Decide whether you wish to register the fetal death. If yes, be prepared to submit the written statement to the local Registrar of Vital Statistics.
  9. If applicable, indicate whether the father will submit the application and ensure he includes a signed and notarized document from you.
  10. Choose whether you would like the physician to handle the disposal of the fetal remains. Mark "Yes" or "No" as appropriate.
  11. Sign and date the form in the designated spaces for the mother.

Document Breakdown

Fact Name Description
Purpose of the Form This form is used by physicians to confirm early pregnancy loss and inform the patient about their rights regarding fetal death certificates.
Positive Pregnancy Test The form certifies that the woman had a positive pregnancy test on a specified date, which is crucial for medical records.
Options for Miscarriage Patients can select from various options regarding their miscarriage, including confirmation of fetal loss or products of conception.
State Registration In many states, parents have the option to register the fetal death with the local Registrar of Vital Statistics.
Disposition of Remains The form allows the mother to designate how she wants the fetal remains to be handled, in accordance with state law, including options for cremation or burial.

FAQ

What is the purpose of the Miscarriage Discharge Paper form?

The Miscarriage Discharge Paper form serves as an official document confirming a miscarriage. It provides essential details about the pregnancy, including the woman's name, dates of tests, and the physician's observations. This form is important for medical records and can also be used to register a fetal death if the parents choose to do so.

What information is included in the form?

The form includes the following key information:

  • The woman's name and the date of her positive pregnancy test.
  • Confirmation of whether the pregnancy was intrauterine via ultrasound.
  • A selection of options regarding the nature of the miscarriage or pregnancy loss.
  • The physician's printed name, signature, and the date of completion.

What options do parents have regarding fetal remains?

Parents have several options for handling fetal remains after a miscarriage. They can choose to:

  1. Have the physician dispose of the remains in accordance with state law.
  2. Arrange for private funeral services and burial.
  3. Request cremation without ashes, which is typically offered at no charge.

To proceed with any of these options, parents must sign a disposition form indicating their choice.

How can parents register a fetal death?

In certain states, parents have the option to register a fetal death. To do this, they must submit the Miscarriage Discharge Paper form to the local Registrar of Vital Statistics in the district where the fetal death occurred. If the father submits the application, he needs to include a signed and notarized document from the mother, confirming that she provided him with a copy of the statement.

Is there a cost associated with the services outlined in the form?

Generally, there is no charge for the service of cremation without ashes. However, costs may vary if parents choose to arrange private funeral services or burial. It is advisable to discuss any potential fees with the physician or funeral service provider beforehand.

What should parents do if they have questions about the form?

If parents have questions or concerns about the Miscarriage Discharge Paper form, they should reach out to their healthcare provider. Physicians can offer guidance on the completion of the form, the options available, and any next steps that may be necessary. It's important to address these questions promptly to ensure that parents feel supported during this difficult time.

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Miscarriage Discharge Paper Example

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: _________________________