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Driscoll sterilization consent form

Sterilization Consent Form - English - Driscoll Health Plan 2026

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The document is a Sterilization Consent Form for Driscoll Health Plan, outlining the process and requirements for individuals seeking sterilization. It emphasizes that the decision to undergo sterilization is voluntary, permanent, and will not affect eligibility for federal benefits. The form includes sections for client information, consent details, interpreter statements, and signatures from the client, interpreter, and physician. It also provides information on alternative birth control methods and ensures that clients understand the risks and permanence of the procedure.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Client Medicaid or Family Planning Number at the top of the form.
Select whether this is an initial submission or a corrected form by checking the appropriate box.
Fill in the date you signed the form using the format (month/day/year).
Read through the consent section carefully, ensuring you understand your rights and the implications of sterilization. Confirm that you have received information from your doctor or clinic.
Specify the type of sterilization operation you are consenting to and provide your birth date.
Sign and date the form where indicated, ensuring all required fields are completed.
If applicable, complete sections for interpreter assistance and statements from those obtaining consent, including signatures and dates.

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2014	4.9 Satisfied (57 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is spousal consent required for sterilization?

The consent of the spouse is not required even if it incidentally will result in the sterilization of the patient. Statutes in Georgia, North Carolina, and Virginia requie the written consent of the patients spouse to voluntary sterilizations.

What are the legal requirements for tubal ligation?

Interval sterilization should be performed within 7 days of the menstrual period (in the follicular phase of the menstrual cycle). Post-partum sterilization should be done after 24 hours up to 7 days of delivery. Sterilization with medical termination of pregnancy (MTP) can be performed concurrently.

What is the sterilization form?

In 1974, the federal sterilization consent form (SCF) was created for those with publicly funded insurance to document appropriate informed consent by a clinician for sterilization procedures.

What are the criteria for sterilization?

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 a sterilization consent good for?

30 days (but not more than 180 days) must pass after the sterilization consent form has been signed. The 30 days starts the day after the consent is signed. Private Pay patients may request in writing that procedure be performed in less than 30 days.

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