Pm 284 2025

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The document is a sterilization consent form from the California Department of Public Health, outlining the process and requirements for individuals seeking sterilization. It emphasizes that the decision to undergo sterilization is voluntary, can be revoked at any time, and will not affect access to federally funded health services. The form details the nature of the procedure (Bilateral Tubal Ligation), associated risks, benefits, and alternative birth control methods. It also includes sections for signatures from the individual consenting to sterilization, the person obtaining consent, and a physician.

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Click ‘Get Form’ to open the pm 284 in the editor.
Begin by filling in your personal information, including your name and date of birth. Ensure accuracy as this information is crucial for consent.
In the 'Consent to Sterilization' section, read through the statements carefully. Confirm your understanding of the procedure and its permanence by checking the appropriate boxes.
If applicable, indicate whether you wish to waive the 30-day waiting period by filling in the number of days you wish to waive.
Complete the 'Signature' field with your signature and date. Make sure to review all entries for correctness before finalizing.
If an interpreter was used, ensure their statement is filled out accurately, confirming they have translated all necessary information.

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How many years does sterilization last?

Supplies wrapped in double-thickness muslin comprising four layers, or equivalent, remain sterile for at least 30 days. Any item that has been sterilized should not be used after the expiration date has been exceeded or if the sterilized package is wet, torn, or punctured.

What is a PM330 consent form?

CONSENT FORM PM 330 State of California -- Health and Human Services Agency NOTICE Department of Health Services 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.

How long is sterilization good for?

The physician certifies, by signing the sterilization consent form, that they advised the member to be sterilized that no federal benefits will be withdrawn if the member chooses not to be sterilized, explained the requirements for informed consent, and, to the best of their knowledge and belief, the member to be

How long is a sterilization consent good for?

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. Specify Type of Operation consent expires 180 days from the date of my signature below.

How long is a consent form valid?

Sterilization is intended to be permanent. People who may want more children should choose a different family planning method. Surgery to reverse sterilization is possible for only some womenthose who have enough fallopian tube left. Even among these women, reversal often does not lead to pregnancy.