The Medical Assistance Program will deny payment to physicians, hospitals, surgi-clinics, anesthesiologists, anesthetists, or any provider billing for services involving sterilization unless the Consent Form for Sterilization is in compliance.
The Sterilization Consent Form must be accurately completed and attached to the claim.
Instructions for completing the form are as follows:
1. That they may withdraw their consent at any time prior to sterilization and that the withdrawal will not affect any program benefits.
2. A description of alternative methods of birth control.
3. The procedure is considered to be irreversible.
4. An explanation of the sterilization procedure to be performed.
5. An explanation of discomforts and risks of the sterilization procedure, including anesthetic risks.
6. A full description of the benefits that may be expected.
7. An explanation that the sterilization cannot be performed for at least 30 days except for circumstances listed under “Exceptions”.
The informed consent for sterilization is not to be obtained while the individual is:
In the event of a premature delivery, the following must occur:
In the event a sterilization is performed during an emergency abdominal surgery, the following must occur:
Mail your completed form to: