MSA-1959 (1/2022) Previous edition may be used
CONSENT FOR STERILIZATION
Michigan Department of Health and Human Services
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.
CONSENT TO STERILIZATION
I have asked for and received information about sterilization from
____________________________________. When I first 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 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
_______________________________. 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 thirty days
after I sign this form. 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 ______________________
(Month / Day / Year)
I, __________________________________________________
(Name of Individual Being Sterilized)
hereby consent of my own free will to be sterilized by
____________________________________________________
(Name of Doctor and Professional Degree)
by a method called _________________________________________ .
My consent expires 180 days from the date of my signature below.
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.
___________________________________ Date: ______________
(Signature of Person Giving Consent) (Month / Day / Year)
You are requested to supply the following information, but it is
not required: Ethnicity and race designation (please check)
Ethnicity: Race (mark one or more):
Hispanic or Latino American Indian or Alaska Native
Not Hispanic or Latino Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
INTERPRETER’S STATEMENT
If an interpreter is provided to assist the individual to be sterilized:
I have translated the information and advice presented orally to the
individual to be sterilized by the person obtaining this consent. I have also
read him/her the consent form in __________________________________
language and explained its contents to him/her. To the best of my
knowledge and belief he/she understood this explanation.
___________________________________ Date: ______________
(Interpreter's Signature) (Month / Day / Year)
STATEMENT OF PERSON OBTAINING CONSENT
Before __________________________________ signed the
(Name of Individual)
consent form, I explained to him/her the nature of the sterilization 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.
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 consequences of the procedure.
_______________________________________ __________________
(Signature of person obtaining consent) (Date)
____________________________________________________________
(Facility)
____________________________________________________________
(Facility Address)
PHYSICIAN’S STATEMENT
Shortly before I performed a sterilization operation upon
_________________________________ on ______________________
(Name of individual to be sterilized) (Date of sterilization)
I explained to him/her the nature of the sterilization operation
_____________________________________ , the fact that it is intended
(specify type of operation)
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.
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 thirty 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 was performed less than 30 days but more than 72
hours after the date of the individual’s signature on this consent form
because of the following circumstances (check applicable box and fill in
information requested):
Premature delivery
Individual's expected date of delivery: ________________________
Emergency abdominal surgery: _____________________________
(describe circumstances)
____________________________________________________________
_______________________________________ Date: ______________
(Signature of Physician and Professional Degree) (Month / Day / Year)
MSA-1959 (1/2022) Previous edition may be used
INSTRUCTIONS TO COMPLETE CONSENT FOR STERILIZATION FORM
1. Name of the physician or clinic giving information to the beneficiary. The "M.D." or "D.O." designation
must be included.
2. Name of the sterilization procedure to be performed (e.g., Tubal Ligation or Vasectomy).
3. Beneficiary’s complete birth date (month, day, and year). The beneficiary must be 21 years of age at
the time they sign the form.
4. Beneficiary’s full name. If a name change is indicated on the Medicaid card by the time surgery is
performed, both names must be indicated.
5. Name of physician performing the sterilization. If the physician is unknown, "doctor on call" may be
indicated.
6. Name of surgery to be performed (e.g., Tubal Ligation or Vasectomy).
7. Beneficiary’s handwritten signature. A beneficiary who cannot write should sign with an "X." The "X"
signature must be witnessed. The witness’ handwritten signature must appear below item 7.
8. Date the consent form was signed (month, day and year). This date must be more than 30 days and
less than 180 days before the date the sterilization is performed. If it is less than 30 days, see
instructions for "alternative final paragraphs."
9. Race and ethnicity designation is optional.
10. Interpreter’s Statement. This information is only required if the beneficiary is unable to understand
English. The language used for interpretation must be specified (e.g., Spanish). The interpreter’s
handwritten signature and date must appear. The date must be the same date the beneficiary signed
the form.
11. Name of beneficiary.
12. Name of sterilization procedure (e.g., Tubal Ligation or Vasectomy).
13. The handwritten signature of the person obtaining consent.
14. Date consent is taken (month, day and year). This date must be before the date sterilization is
performed (#18).
15. Name of provider or clinic (e.g., office of John Doe, M.D., doctor’s office, ABC Clinic, XYZ Hospital).
16. Street address, city, state, and zip code. No P.O. boxes allowed.
17. Beneficiary’s full name.
18. Date of sterilization (month, day, and year). The surgery date must be the same as indicated on the
claim.
19. Name of sterilization procedure (e.g., Tubal Ligation, Vasectomy).
20. Instructions for use of alternative final paragraphs.
21. If at least 30 days have passed since the date the beneficiary signed the consent form and the date of
sterilization, paragraph "1" applies and paragraph "2" should be crossed out.
22. If the date the sterilization was performed is less than 30 days and more than 72 hours of the
beneficiary signing the consent form, paragraph "2" applies and paragraph "1" should be crossed out.
The applicable box should be checked.
23. For premature delivery, the expected date of delivery must be given.
24. Physician’s signature. This can be a stamped signature if counter initialed.
25. Date physician signed the consent form. This date must be on or after the date of surgery. This can
be typed or stamped.
If abdominal surgery was performed, the circumstances must be explained and operative notes submitted with the claim.
AUTHORITY: Title XIX of the Social Security Act The Michigan Department of Health and Human Services is an
COMPLETION: Is Voluntary, but is required if Medical Assistance program equal opportunity employer, services and programs provider.
payment is desired.
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or
group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information
that is unrelated to the person’s eligibility
