Get Mi Msa-1959 2022-2025

This guide provides a clear and comprehensive overview of how to complete the MI MSA-1959 form online. Whether you are familiar with sterilization procedures or not, this step-by-step approach will help ensure that all necessary information is accurately filled out.

Follow the steps to complete the MI MSA-1959 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter the name of the physician or clinic providing information to you. Ensure to include the 'M.D.' or 'D.O.' designation.
3. Specify the name of the sterilization procedure that will be performed, such as Tubal Ligation or Vasectomy.
4. Input your complete birth date (month, day, and year). It is important that you are at least 21 years old at the time of signing the form.
5. Fill in your full name. If your Medicaid card reflects a name change by the time of surgery, indicate both names.
6. Specify the name of the physician performing the sterilization. If unknown, you may note 'doctor on call'.
7. State the method of surgery to be performed again, ensuring clarity.
8. Place your handwritten signature on the form. If you cannot write, you may sign with an 'X,' which must be witnessed.
9. Record the date when the consent form was signed (month, day, and year). This date must be more than 30 days but less than 180 days prior to the date of sterilization.
10. Complete the optional section for race and ethnicity designation, if desired.
11. If applicable, include an interpreter’s statement, detailing any assistance provided for understanding the consent form.
12. Finalize the document by ensuring the signatures and all necessary fields are complete. Save changes, download, print, or share the form as needed.

Complete your documents online for efficient processing and peace of mind.