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  • Medicaid Sterilization Consent Form 2020

Get Medicaid Sterilization Consent Form 2020

Form Approved: OMB No. 0937-0166 Expiration date: 10/31/2015 CONSENT FOR STERILIZATION NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY.

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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.

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.

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.)

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.

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.

Medicaid shall cover sterilization procedures for both men and women age 21 and over that meet requirements found in 42 CFR Part 441, Subpart F – Sterilization and this clinical coverage policy.

Sterilization may be performed at the time of premature delivery if the following requirements are met: – The written informed consent was given at least 30 days before the expected date of the delivery, and – At least 72 hours have passed after written informed consent to be sterilized was given.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232