Sterilization Consent Form

LDSS-3134 (2/01)

PATIENT NAME CHART NO. RECIPIENT ID NO.

STERILIZATION

CONSENT FORM

HOSPITAL/CLINIC

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.

■ CONSENT TO STERILIZATION ■

I have asked for and received information about sterilization from

__________________________________. When I asked for the

(doctor or clinic)

information, I was told that the decision to be sterilized is completely

up to me. I was told that I could decide not to be sterilized. If I decide

not to be sterilized, my decision will not affect my right to future care

or treatment. I will not lose any help or benefits from programs

receiving Federal funds, such as A.F.D.C. or Medicaid that I am now

getting or for which I may become eligible.

I UNDERSTAND THAT THE STERILIZATION MUST BE

CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE

DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR

CHILDREN OR FATHER CHILDREN.

I was told about those temporary methods of birth control that are

available and could be provided to me which will allow me to bear or

father a child in the future. I have rejected these alternatives and

chosen to be sterilized.

I understand that I will be sterilized by an operation know as a

_______________________. The discomforts, risks and benefits

associated with the operation have been explained to me. All my

questions have been answered to my satisfaction.

I understand that the operation will not be done until at least thirty

days after I sign this form. I understand that I can change my mind at

any time and that my decision at any time not to be sterilized will not

result in the withholding of any benefits or medical services provided

by federally funded programs.

I am at least 21 years of age and was born on ______________

Month Day Year

I, ____________________________, hereby consent of my own

free will to be sterilized by _________________________________

(Doctor)

by a method called _____________________________. My consent

expires 180 days from the date of my signature below.

I also consent to the release of this form and other medical records

about the operation to: Representatives of the Department of Health,

Education, and Welfare or Employees of programs or projects funded

by that Department but only for determining if Federal laws were

observed.

I have received a copy of this form.

_____________________________________Date: ____________

Signature Month Day Year

You are requested to supply the following information, but it is not

required:

Race and ethnicity designation (please check)

□ 1 American Indian or □ 4 Hispanic

Alaska Native

□ 2 Asian or Pacific Islander □ 5 White (not of Hispanic origin)

□ 3 Black (not of Hispanic origin)

■ INTERPRETER’S STATEMENT ■

If an interpreter is provided to assist the individual to be sterilized:

I have translated the information and advice presented orally to the

individual to be sterilized by the person obtaining this consent. I have

also read him/her the consent form in

____________________________ language and explained its

contents to him/her. To the best of my knowledge and belief he/she

understood this explanation.

_______________________________________ ______________

Interpreter Date

■ STATEMENT OF PERSON OBTAINING CONSENT■

Before _____________________________________ signed the

Name of Individual

consent form, I explained to him/her the nature of the sterilization

operation _____________________, the fact that it is intended to be

a final and irreversible procedure and the discomforts, risks and

benefits associated with it.

I counseled the individual to be sterilized that alternative methods

of birth control are available which are temporary. I explained that

sterilization is different because it is permanent.

I informed the individual to be sterilized that his/her consent can be

withdrawn at any time and that he/she will not lose any health

services or any benefits provided by Federal funds.

To the best of my knowledge and belief the individual to be

sterilized is at least 21 years old and appears mentally competent.

He/She knowlingly and voluntarily requested to be sterilized and

appears to understand the nature and consequence of the

procedure.

Signature of person obtaining consent Date

Facility

Address

■ PHYSICIAN’S STATEMENT ■

Shortly before I performed a sterilization operation upon

____________________________________ on _______________

Name of individual to be sterilized Date of sterilization

_________________________________, I explained to him/her the

Operation

nature of the sterilization operation _____________________, the

Specify type of operation

fact that it is intended to be a final irreversible procedure and the

discomforts, risks and benefits associated with it.

I counseled the individual to be sterilized that alternative methods

of birth control are available which are temporary. I explained that

sterilization is different because it is permanent.

I informed the individual to be sterilized that his/her consent can be

withdrawn at any time and that he/she will not lose any health

services or benefits provided by Federal funds.

To the best of my knowledge and belief the individual to be

sterilized is a least 21 years old and appears mentally competent.

He/She knowingly and voluntarily requested to be sterilized and

appeared to understand the nature and consequences of the

procedure.

Instructions for use of alternative final paragraphs: Use the

first paragraph below except in the case of premature delivery or

emergency abdominal surgery where the sterilization is performed

less than 30 days after the date of the individual’s signature on the

consent form. In those cases, the second paragraph below must be

used. (Cross out the paragraph which is not used.)

(1) At least thirty days have passed between the date of the

individual’s signature on this consent form and the date

sterilization was performed.

(2) This sterilization was preformed less than 30 days but more

than 72 hours after the date of the individual's signature on

this consent form because of the following circumstances

(check applicable and fill in information requested):

□ 1. Premature delivery

Individual’s expected date of delivery: ______________

□ 2. Emergency abdominal surgery: ___________________

(describe circumstances ): ____________________________

________________________________ ________________

Physician Date

THE FOLLOWING MUST BE COMPLETED FOR STERILIZATIONS PERFORMED IN NEW YORK CITY -- WITNESS CERTIFICATION

I, __________________________ do certify that on _____________________________ I was present while the counselor read and explained the consent

form to _________________________________ and saw the patient sign the consent form in his/her handwriting.

(patient’s name)

SIGNATURE OF WITNESS

X

TITLE DATE

REAFFIRMATION (to be signed by the patient on admission for Sterilization)

I certify that I have carefully considered all the information, advice and explanations given to me at the time I originally signed the consent form.

I have decided that I still want to be sterilized by the procedure noted in the original consent form, and I hereby affirm that decision.

SIGNATURE OF PATIENT

X

DATE SIGNATURE OF WITNESS

X

DATE

DISTRIBUTION: 1 – Medical Record File 2 – Hospital Claim 3- Surgeon Claim 4 – Anesthesiologist Claim 5 – Patient