STERILIZATION CONSENT FORM INSTRUCTIONS: COMPLETE AND DISTRIBUTE COPIES TO: ORIGINAL - PHYSICIAN; COPY - HOSPITAL; COPY - PATIENT; COPY - DPW, OFFICE OF MEDICAL ASSISTANCE PROGRAMS 1. Patient Name 2. Recipient Number NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. I CONSENT TO STERILIZATION I I have asked for and received information about sterilization from 3._______________________________ (doctor or clinic). When I first asked for the 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 not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a 4._____________________________________. The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least 30 days but no more than 180 days after I sign this form. I understand that based on my signing of this form, the operation can be performed between 5.____________________(date) and 6.___________________(date). I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by Federally funded programs. I am at least 21 years of age and was born on 7.______________________________(mm/dd/yyyy). I, 8._______________________________________, hereby consent of my own free will to be sterilized by 9.________________________________ (doctor) and/or an associate by a method called 10._____________________________________ (specify type of operation). My consent expires 180 days from the date of my signature below. I understand that although the operation works almost all the time, it cannot be guaranteed 100% to make me sterile. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed. I have received a copy of this form. 11._______________________________________________(signature) 12.__________________________(date; mm/dd/yyyy) You are requested to supply the following information, but it is not required. 13. Race and ethnicity designation (please check) I American Indian or Alaska Native I Asian or Pacific Islander I Black (not of Hispanic origin) I Hispanic I White (not of Hispanic origin) I STATEMENT OF PERSON OBTAINING CONSENT I Before 17._______________________________ (name of individual) signed the consent form, I explained to him/her the nature of the sterilization operation 18._______________________________ (specify type of operation), the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent and works almost all the time but cannot be guaranteed 100% to make him/her sterile. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure. 19._______________________________________________(Signature of person obtaining consent) 20._______________________________(date) 21.____________________________________________________(facility) 22.___________________________________________________(address) I PHYSICIAN'S STATEMENT I Shortly before I performed a sterilization operation upon 23._______________________________ (name of individual to be sterilized) on 24._______________________________ (date of sterilization operation), I explained to him/her the nature of the sterilization operation 25.____________________________________(specify type of operation), the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent and works almost all of the time, but cannot be guaranteed 100% to make him/her sterile. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.) (1) At least 30 days but not more than 180 days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed. (2) This sterilization wa