Get Sterilization Consent Form 2021-2024

You can have your tubes tied at any time in your life. For Medicaid to pay for the opera- tion, you must be at least 21 years of age. You can have your tubes tied even if you are married or if you do not have children.

The consent form should include the name and telephone number of a person to contact for answers to questions and a person to contact in the event of a research-related injury or emergency.

A document with important information about a medical procedure or treatment, a clinical trial, or genetic testing. It also includes information on possible risks and benefits. If a person chooses to take part in the treatment, procedure, trial, or testing, he or she signs the form to give official consent.

At least 21 years old at the time the Consent for Sterilization form is signed. Voluntarily sign the Consent for Sterilization (PDF) form (MHCP will not accept a consent form signed by a guardian, conservator or anyone other than the person to be sterilized.)

The consent form should include the name and telephone number of a person to contact for answers to questions and a person to contact in the event of a research-related injury or emergency.

A completed PM 330 Sterilization Consent Form must accompany all claims directly related to the sterilization surgery. This requirement extends to all providers, attending physicians, surgeons, assistant surgeons, anesthesiologists and facilities.

Patient/parental agreement to investigation or treatment. (Procedure where consciousness not impaired) Patient details (or pre-printed label)

Consent Forms Consent Form 1 – Patient agreement to investigation, treatment or procedure. Consent Form 2 – Parental agreement to investigation, treatment or procedure for a child or young person. Consent Form 3 – Patient Parental agreement to investigation, treatment or procedure where consciousness not impaired.

Medical devices are sterilized in a variety of ways including using moist heat (steam), dry heat, radiation, ethylene oxide gas, vaporized hydrogen peroxide, and other sterilization methods (for example, chlorine dioxide gas, vaporized peracetic acid, and nitrogen dioxide).