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Department Of Health & Human Services - Individuals Informed Consent To Non - Therapeutic Sterilization For Medicaid Recipients Page 3

Managed Care Organization Policy and Procedure Guide

February 2005

Revised April 2007

12.

Signature and date of the person who counseled the member on the sterilization

procedure. This date should match the date of the member’s signature date.

Also complete the facility address. An address stamp is acceptable if legible.

Part IV (This part is completed after the sterilization procedure is

performed).

13.

Member’s name.

14.

Date of the sterilization procedure. (Be sure this date matches the date on the

claim.)

15.

Name of the sterilization procedure.

16.

EDC date is required if sterilized within the 30 day waiting period and the

member was pregnant.

17.

An explanation must be attached if an emergency abdominal surgery was

performed within the 30 day waiting period. At least 72 hours is required to pass

before the sterilization and the sterilization procedure may not be the reason for

the emergency surgery.

Please note: If the member is pregnant, premature delivery is the only

exception to the 30 day waiting period.

18.

Physician signature and date. A physician's stamp is acceptable. The rendering

or attending physician must sign the consent form. The physician's date must be

dated the same as the sterilization date or after.

187

CMS Approved February 2005

Revisions Approved April 2007

Department Of Health & Human Services - Individuals Informed Consent To Non - Therapeutic Sterilization For Medicaid Recipients Page 3