Form Dmap 742a - Consent To Sterilization - 2011
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Client Name
Consent to
Medicaid ID Number
Client sex
Sterilization
q
q
Female
Male
Notice: Your decision at any time not to be sterilized will not result in the withdrawal or withholding of any
benefits provided by programs or projects receiving Federal funds.
Patient's Statement
I have asked for and received information about
until at least 30 days after I sign this form. I
sterilization from___________________________
understand that I can change my mind at any
(doctor or clinic).
time and that my decision at any time not to be
sterilized will not result in the withholding of any
When I first asked for the information, I was told
benefits of medical services provided by Federally
that the decision to be sterilized is completely
funded programs.
up to me. I was told that I could decide not to
be sterilized. If I decide not to be sterilized, my
I am at least 21 years of age and was born on
decision will not affect my right to future care or
__________ (month/day/year).
treatment. I will not lose any help or benefits from
I, __________________________________, hereby
programs receiving Federal funds; such as AFDC
consent of my own free will to be sterilized by
or Medicaid that I am now getting or for which I
________________________(doctor) by a method
may become eligible.
called ___________________________________.
I understand that the sterilization must be
My consent expires 180 days from the date of my
considered permanent and not reversible. I have
signature below. I also consent to the release of
decided that I do not want to become pregnant,
this form and other medical records about the
bear children or father children.
operation to: Representatives of the Department
I was told about those temporary methods of birth
of Health (DH) and Oregon Health Authority (OHA)
control that are available and could be provided
or Employees of programs or projects funded by
to me which will allow me to bear or father a child
the DH but only for determining if Federal laws
in the future. I have rejected these alternatives
were observed. I have received a copy of this form.
and chosen to be sterilized.
Signature _________________________________
I understand that I will be sterilized by an
Date ______________ (month/day/year).
operation known as a ___________________.
You are requested to supply the following
The discomforts, risks and benefits associated
information, but it is not required: Race
with the operation have been explained to me.
and ethnicity designation (please check)
All my questions have been answered to my
q Black (not of
q White (not of
satisfaction.
Hispanic origin)
Hispanic origin)
I understand that the operation will not be done
q Asian/Pacific Islander
q American Indian/
Alaska Native
q Hispanic
Interpreter's Statement
If an interpreter is provided to assist the
form in ________________________language and
individual to be sterilized: I have translated
explained its contents to him/her. To the best of
the information and advice presented orally to the
my knowledge and belief he/she understood this
individual to be sterilized by the person obtaining
explanation.
this consent. I have also read him/her the consent
Interpreter's Signature________________________
Date _________________ (month/day/year).
DMAP 742A (Rev. 07/11)
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