MO HealthNet Provider Training Program: Proper Completion of a Sterilization Consent Form

1. MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit MO HealthNet Division MO HealthNet Division

2. Proper Completion of a Paper Sterilization Consent Form Presented by the Provider Education Unit MO HealthNet Division MO HealthNet Division

3. Procedure Codes That Require a Sterilization Consent Form • 55250 – Vasectomy, unilateral or bilateral, including postoperative semen examination. • 58565 – Hysteroscopy, Sterilization. • 58600 – Ligation or Transection of Fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral. • 58605 – Ligation or Transection of Fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral. • 58611 – Ligation/Transection-Fallopian tube(s) when done at same time as cesarean delivery. MO HealthNet Division

4. Procedure Codes that Require a Sterilization Consent Form (Continued) • 58615 – Occlusion of Fallopian tube(s) by device, (eg, Band, Clip, Falope Ring) vaginal or suprapubic approach. • 58670 – Laproscopy, surgical; with fulguration of oviducts (with or without transection). • 58671 – Laparoscopy, surgical; with occlusion of oviducts by device (eg, Band, Clip, or Falope Ring). MO HealthNet Division

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6. Doctor or Clinic MO HealthNet Division

7. Name of Operation MO HealthNet Division

8. Participant Date of Birth Physician Name Patient Name Method of Sterilization Participant Signature Date (Month/day/year) MO HealthNet Division

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10. Language of Interpreter Signature of Interpreter Date (Month/Day/Year MO HealthNet Division

11. Name of Individual Name of Operation Date (Month/Day/Year) Signature of Individual Facility Name Facility Address MO HealthNet Division

12. Participant Name MO HealthNet ID Number Date of Sterilization Name of Operation MO HealthNet Division

13. Describe Circumstances Date (Month/Day/Year) Physician Signature MO HealthNet Provider Identifier Taxonomy Code MO HealthNet Division

14. The MO HealthNet participant must be at least 21 years of age at the time consent is obtained. There are not exceptions (42 CFR 441.253). • The MO HealthNet participant must not be a mentally incompetent individual or an institutionalized individual (42 CFR 441.251). • The MO HealthNet participant must have voluntarily given informed consent. MO HealthNet Division

15. Informed consent for a sterilization procedure may not be obtained from a participant under the following conditions: • The participant is in labor or childbirth. • The participant is seeking to obtain or is obtaining an abortion. • The participant is under the influence of alcohol or other substances that affect the individual’s state of awareness. MO HealthNet Division

16. Exceptions to the Time Requirements for the Sterilization Consent Form • Premature delivery: The Sterilization Consent Form must be completed and signed by the participant at least 72 hours prior to sterilization and at least 30 days prior to the expected date of delivery. Expected date of delivery is required on the Sterilization Consent Form. MO HealthNet Division

17. Exceptions to the Time Requirements for the Sterilization Consent Form • Emergency abdominal surgery: The Sterilization Consent Form must be completed and signed by the participant at least 72 hours prior to sterilization. The nature of the emergency abdominal surgery must be documented on the Sterilization Consent Form. MO HealthNet Division

18. Obtaining a Copy of the Paper Form To obtain a copy of the form, go to the MHD public Web site, www.dss.mo.gov/mhd/providers/index.htm. In the left hand column, click on “MO HealthNet Forms”. When the index of forms opens, click on Sterilization Consent Form. You then can print the form once it opens up on your computer screen. MO HealthNet Division

19. You may either mail the completed Sterilization Consent Form to Infocrossing Healthcare Services, P.O. Box 5900, Jefferson City, MO 65102 or you may enter the information from this form via the Internet at www.emomed.com. MO HealthNet Division

20. Thank you again for participating in this training program. If you have questions regarding the information in this presentation, please contact the Provider Education Unit at 573-751-6683. MO HealthNet Division