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Department Of Health & Human Services - Individuals Informed Consent To Non - Therapeutic Sterilization For Medicaid Recipients Page 2

Managed Care Organization Policy and Procedure Guide

February 2005

Revised April 2007

INSTRUCTIONS FOR COMPLETING THE STERILIZATION CONSENT FORM

All sections of the "Sterilization for Medicaid Recipients" consent form (SCDHHS form

1723, Jan. 1989 edition) must be completed. If the consent form is correctly completed

and meets the Federal Regulations, the service may be rendered. Please see the

Correctable/Non-Correctable Error Chart for a listing of errors that can and cannot be

changed on a Consent form. Listed below are instructions on completing the form

followed by the Error Chart.

Part I

Name of physician or group scheduled to do sterilization procedure.

If the

physician or group is unknown, put the phrase "OB on call".

Name of the sterilization procedure (i.e., bilateral tubal ligation [BTL]).

Birth date of the member. The member must be 21 years old when he/she

signs the consent form.

Member’s name.

Name of the physician or group scheduled to do the sterilization or the phrase

"OB on call".

Name of the sterilization procedure.

Member’s signature and date. If the member signs with an "X", an explanation

must accompany the consent form.

Member’s Medicaid number.

Part II

If the member had an interpreter translate the consent form information in a

foreign language (i.e., Spanish, French, etc.), the interpreter must complete this

section. If an interpreter was not necessary, put N/A in these blanks.

Part III

10.

Member’s name.

11.

Name of sterilization procedure.

186

CMS Approved February 2005

Revisions Approved April 2007

Department Of Health & Human Services - Individuals Informed Consent To Non - Therapeutic Sterilization For Medicaid Recipients Page 2