Form Hca13-365 - Hysterectomy Consent And Patient Information Form


Hysterectomy Consent and Patient Information Form
This hysterectomy would be performed even without the purpose of rendering
permanently incapable of reproducing
Patient's Name
because of medical reasons (purposes) unrelated to sterilization:
The reasons are:
Physician's Signature
Explained by:
I told
and her representative
(If one present)
both orally and in writing, that the medical procedure - hysterectomy - will render her permanently incapable of reproducing.
Signature of Person Obtaining Surgical Consent
I have received and understand both oral and written information explaining that a woman undergoing a hysterectomy will be
permanently incapable of reproducing:
Signature of Patient
Acknowledgment was not required because of one or more of the following circumstance(s) (Check applicable box):
The individual was sterile at time of procedure due to
The individual required a hysterectomy on an emergency basis because of life threatening circumstances.
Physician's Signature
This form is to be completed for requests for hysterectomies. An additional sterilization consent form is not required. Attach
one copy to Health Insurance Claim Form -- Washington State (HCFA 1500) when requesting authorization for surgery from the
department. A copy must go to the patient and one to her representative if present. The physician should also retain a copy.
HCA13-365 (09/16)


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