
R WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. ■ CONSENT TO STERILIZATION ■ ■ STATEMENT OF PERSON OBTAINING CONSENT■ 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 .
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How to fill out the NY LDSS-3134 online
The NY LDSS-3134 form is a sterilization consent form that individuals must complete before undergoing a sterilization procedure. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently while using online technologies.
Follow the steps to complete the NY LDSS-3134 online.
- Click ‘Get Form’ button to access the form and view it online.
- Begin by entering the recipient's name and chart number at the top of the form. These identifiers help to ensure that the form is accurately linked to the individual's medical records.
- Input the recipient ID number and the name of the hospital or clinic where the sterilization will take place.
- In the consent section, provide the name of the doctor or clinic from whom you received information regarding the sterilization.
- State your decision regarding sterilization, indicating that you understand the procedure is permanent and that you have considered alternatives.
- Fill in the method of sterilization, ensuring you understand the associated discomforts, risks, and benefits.
- Sign and date the form to confirm your consent and that you have received a copy of the document.
- If applicable, have the interpreter complete their statement in the designated area, ensuring that the language is appropriately noted.
- The person obtaining consent should also provide their signature and the date, asserting that the individual understood the information related to their sterilization.
- Finally, save your changes, download or print the completed form to share it with necessary medical personnel.
Complete the NY LDSS-3134 online now to ensure your sterilization consent is processed correctly.
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