Department Of Health & Human Services - Individuals Informed Consent To Non - Therapeutic Sterilization For Medicaid Recipients Page 4
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4Managed Care Organization Policy and Procedure Guide
February 2005
Revised April 2007
Correctable/Non-Correctable Error Chart for Sterilization Consent Form
A.
Doctor or Group Name
Correctable Error
B.
Name of Procedure
Correctable Error
C.
Patient Date of Birth
Correctable Error. Date of Birth on the CMS 1500
form, and consent form should all match. Patient
MUST be 21 years old to sign form.
D.
Patient Name
Correctable Error. Name should match name on the
CMS 1500 form.
E.
Doctor or Group Name
Correctable Error
F.
Name of Procedure
Correctable Error
G.
Patient Signature
NOT A CORRECTABLE ERROR. The signature
must be the patient’s signature. If the patient is
unable to sign or signs with an “X”, an explanation
must accompany the consent form.
G.
Date
NOT A CORRECTABLE ERROR without detailed
medical records documentation.
H.
Medicaid ID Number
Correctable Error
Part II – Interpreter’s Statement
A.
Foreign Language Used
Correctable Error
A.
Interpreter Signature
Correctable Error
A.
Date
Correctable Error
Part III – Statement of Person Obtaining Consent
A.
Patient Name
Correctable Error
B.
Procedure
Correctable Error. This procedure must match B
and F.
C.
Signature of Person Obtaining Consent
NOT A CORRECTABLE ERROR
C.
Date
NOT A CORRECTABLE ERROR without detailed
medical records documentation. This date must
match PARTI-G. *
C.
Facility Address
Correctable Error. An address stamp is acceptable
if legible.
Part IV – Physician’s Statement
A.
Patient’s Name
Correctable Error
B.
Date of Procedure
Correctable Error. This date must match the date of
service on the claim form.
C.
Procedure
Correctable Error. This procedure must match
PART I B and F, and procedure code on claim.
D.
Expected Date of Delivery
Correctable Error
D.
Emergency Abdominal Surgery
Correctable Error. An explanation must be attached
to the claim.
F.
Physician Signature
Correctable Error. A physician’s stamp is
acceptable.
F.
Date
NOT A CORRECTABLE ERROR if the date is prior
to the sterilization without detailed medical records
documentation. *
CORRECTABLE ERROR if field is blank.
F.
License Number (Medicaid Individual Provider
Correctable Error. The provider number is the same
Number)
as on the CMS claim form.
F.
Group Number (Medicaid Group Provider
Correctable Error. The group provider number is the
Number)
same as on the CMS claim form.
* Most commonly occurring errors.
188
CMS Approved February 2005
Revisions Approved April 2007
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