Provider Information

Prior Authorization Request Services and Forms

Sterilization

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:

• Provide a copy of the consent form to the individual to be sterilized.
• Offer to answer any questions the individual has about sterilization.
• Give the following information to the person to be sterilized:

  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”.

• Arrangements will be made to effectively inform the blind, deaf and those who do not understand the language.

The informed consent for sterilization is not to be obtained while the individual is:

• In labor or child birth.
• Seeking to obtain or obtaining an abortion.
• Under the influence of alcohol or drugs.

In the event of a premature delivery, the following must occur:

• The consent form must be signed by the individual to be sterilized at least 30 days prior to expected delivery date and at least 72 hours prior to the sterilization.
• The date of the expected delivery must be written on the consent form.

In the event a sterilization is performed during an emergency abdominal surgery, the following must occur:

• The consent form must be signed by the individual to be sterilized at least 72 hours prior to sterilization.
• The physician must describe the surgery and explain the medical necessity of the emergency abdominal surgery.
• A Sterilization is not consider an emergency.

Mail your completed form to:

• South Dakota Department of Social Services
  Division of Medical Services
  700 Governors Drive
  Pierre, SD 57501
• Phone: (605) 773-3495
• Fax: (605) 773-5246