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PM 330 1-99 Eng-SP.doc

PM 330 1-99 Eng-SP.doc 2026

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The document is a consent form for sterilization issued by the State of California's Health and Human Services Agency. It outlines the individual's right to make an informed decision regarding sterilization, emphasizing that their choice will not affect their eligibility for federally funded benefits. The form includes statements from both the individual seeking sterilization and the physician, confirming understanding of the procedure's permanence, risks, and alternatives. It also provides provisions for withdrawal of consent at any time without loss of benefits.

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Click ‘Get Form’ to open the PM 330 1-99 Eng-SP.doc in the editor.
Begin by filling out the 'Name of Individual to be sterilized' section. Ensure that you enter the full name accurately.
In the 'Statement of Person Obtaining Consent' section, provide your name and details about the information shared regarding sterilization. This includes explaining the nature of the procedure and its permanence.
Complete the 'Date of Birth' and 'Address of Facility' fields as required. Make sure all information is current and correct.
The individual being sterilized must sign and date the consent form, confirming their understanding of the procedure and their right to withdraw consent at any time.
If applicable, include details from an interpreter's statement if one was used during counseling. This ensures clarity in communication.
Finally, review all entries for accuracy before saving or printing your completed form.

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