LDSS-3134 (2/01) PATIENT NAME CHART NO. RECIPIENT ID NO.

STERILIZATION HOSPITAL/CLINIC
CONSENT FORM
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 ■ ■ STATEMENT OF PERSON OBTAINING CONSENT■

I have asked for and received information about sterilization from Before _____________________________________ signed the
__________________________________. When I asked for the Name of Individual
(doctor or clinic) consent form, I explained to him/her the nature of the sterilization
information, I was told that the decision to be sterilized is completely operation _____________________, the fact that it is intended to be
up to me. I was told that I could decide not to be sterilized. If I decide a final and irreversible procedure and the discomforts, risks and
not to be sterilized, my decision will not affect my right to future care benefits associated with it.
or treatment. I will not lose any help or benefits from programs I counseled the individual to be sterilized that alternative methods
receiving Federal funds, such as A.F.D.C. or Medicaid that I am now of birth control are available which are temporary. I explained that
getting or for which I may become eligible. sterilization is different because it is permanent.
I UNDERSTAND THAT THE STERILIZATION MUST BE I informed the individual to be sterilized that his/her consent can be
CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE withdrawn at any time and that he/she will not lose any health
DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR services or any benefits provided by Federal funds.
CHILDREN OR FATHER CHILDREN. To the best of my knowledge and belief the individual to be
I was told about those temporary methods of birth control that are sterilized is at least 21 years old and appears mentally competent.
available and could be provided to me which will allow me to bear or He/She knowlingly and voluntarily requested to be sterilized and
father a child in the future. I have rejected these alternatives and appears to understand the nature and consequence of the
chosen to be sterilized. procedure.
I understand that I will be sterilized by an operation know as a
_______________________. The discomforts, risks and benefits
associated with the operation have been explained to me. All my Signature of person obtaining consent Date
questions have been answered to my satisfaction.
I understand that the operation will not be done until at least thirty Facility
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 Address
result in the withholding of any benefits or medical services provided
by federally funded programs. ■ PHYSICIAN’S STATEMENT ■
I am at least 21 years of age and was born on ______________
Month Day Year Shortly before I performed a sterilization operation upon
I, ____________________________, hereby consent of my own ____________________________________ on _______________
free will to be sterilized by _________________________________ Name of individual to be sterilized Date of sterilization
(Doctor) _________________________________, I explained to him/her the
by a method called _____________________________. My consent Operation
expires 180 days from the date of my signature below. nature of the sterilization operation _____________________, the
I also consent to the release of this form and other medical records Specify type of operation
about the operation to: Representatives of the Department of Health, fact that it is intended to be a final irreversible procedure and the
Education, and Welfare or Employees of programs or projects funded discomforts, risks and benefits associated with it.
by that Department but only for determining if Federal laws were I counseled the individual to be sterilized that alternative methods
observed. of birth control are available which are temporary. I explained that
I have received a copy of this form. sterilization is different because it is permanent.
I informed the individual to be sterilized that his/her consent can be
_____________________________________Date: ____________ withdrawn at any time and that he/she will not lose any health
Signature Month Day Year services or benefits provided by Federal funds.
You are requested to supply the following information, but it is not To the best of my knowledge and belief the individual to be
required: sterilized is a least 21 years old and appears mentally competent.
He/She knowingly and voluntarily requested to be sterilized and
Race and ethnicity designation (please check) appeared to understand the nature and consequences of the
□ 1 American Indian or □ 4 Hispanic procedure.
Alaska Native Instructions for use of alternative final paragraphs: Use the
first paragraph below except in the case of premature delivery or
□ 2 Asian or Pacific Islander □ 5 White (not of Hispanic origin) emergency abdominal surgery where the sterilization is performed
□ 3 Black (not of Hispanic origin) 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
■ INTERPRETER’S STATEMENT ■ used. (Cross out the paragraph which is not used.)
(1) At least thirty days have passed between the date of the
If an interpreter is provided to assist the individual to be sterilized: individual’s signature on this consent form and the date
I have translated the information and advice presented orally to the sterilization was performed.
individual to be sterilized by the person obtaining this consent. I have (2) This sterilization was preformed less than 30 days but more
also read him/her the consent form in than 72 hours after the date of the individual's signature on
____________________________ language and explained its this consent form because of the following circumstances
contents to him/her. To the best of my knowledge and belief he/she (check applicable and fill in information requested):
understood this explanation.
□ 1. Premature delivery
_______________________________________ ______________ Individual’s expected date of delivery: ______________
Interpreter Date □ 2. Emergency abdominal surgery: ___________________
(describe circumstances ): ____________________________

________________________________ ________________
Physician Date
THE FOLLOWING MUST BE COMPLETED FOR STERILIZATIONS PERFORMED IN NEW YORK CITY -- WITNESS CERTIFICATION
I, __________________________ do certify that on _____________________________ I was present while the counselor read and explained the consent
form to _________________________________ and saw the patient sign the consent form in his/her handwriting.
(patient’s name)
SIGNATURE OF WITNESS TITLE DATE

X
REAFFIRMATION (to be signed by the patient on admission for Sterilization)
I certify that I have carefully considered all the information, advice and explanations given to me at the time I originally signed the consent form.
I have decided that I still want to be sterilized by the procedure noted in the original consent form, and I hereby affirm that decision.
SIGNATURE OF PATIENT DATE SIGNATURE OF WITNESS DATE

X X
DISTRIBUTION: 1 – Medical Record File 2 – Hospital Claim 3- Surgeon Claim 4 – Anesthesiologist Claim 5 – Patient