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Get Alabama Medicaid Sterilization Consent Form

You will find the consent form at the back of this booklet. MSA-FP-78-10 Form 193 Rev. 2-10-2010 Revised 8-30-02 Alabama Medicaid Agency Why This Information Is Important To You Sterilization tying your tubes is an operation that is meant to make it impossible for you to become pregnant. I am at least 21 years of age and was born on Month/Day/Year Signature Date PHYSICIAN S STATEMENT Shortly before I performed a sterilization operation upon Patie.

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