Commonwealth of Massachusetts • Executive Office of Health and Human Services

Sterilization Consent Form (Ages 21 and Older)

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 with it. I counseled the individual to be sterilized that alternative methods of
I have asked for and received information about sterilization from ________ birth control are available that are temporary. I explained that sterilization is
____________ (physician or clinic). When I first asked for the information, I different because it is permanent. I informed the individual to be sterilized that
was told that the decision to be sterilized was completely up to me. I was he or she may withdraw consent at any time and that he or she will not lose any
told that I could decide not to be sterilized. If I decide not to be sterilized, health services or any benefits provided by federal funds.
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 To the best of my knowledge and belief, the individual to be sterilized is at
AFDC or MassHealth that I am now getting or for which I may become least 21 years old and appears mentally competent. He or she knowingly and
eligible. voluntarily requested to be sterilized and appears to understand the nature and
consequence of the procedure.
I understand the sterilization must be considered permanent and not Signature: __________________________________ Date: _______________
reversible. I have decided that I do not want to become pregnant, bear Facility: ________________________________________________________
Address: _______________________________________________________
children, or father children.
Physician's Statement
I was told about those temporary methods of birth control that are available
Shortly before I performed a sterilization upon _________________________
and could be provided to me that will allow me to bear or father a child in
(name of member) on ___________________ (date), I explained to him or her
the future. I have rejected these alternatives and have chosen to be
the nature of the sterilization operation known as _______________________;
sterilized.
the fact that it is intended to be a final and irreversible procedure; and the
I understand that I will be sterilized by an operation known as a discomforts, risks, and benefits associated with it. I counseled the individual to
______________________________. The discomforts, risks, and benefits be sterilized that alternative methods of birth control are available that are
associated with the operation have been explained to me. All my questions temporary. I explained that sterilization is different because it is permanent. I
have been answered to my satisfaction. informed the individual to be sterilized that he or she may withdraw consent at
any time and that he or she will not lose any health services or benefits
I understand that the operation will not be done until at least 30 days after I provided by federal funds.
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 To the best of my knowledge and belief, the individual to be sterilized is at
of any benefits or medical services provided by federally funded programs. least 21 years old and appears mentally competent. He or she knowingly and
voluntarily requested to be sterilized and appeared to understand the nature and
I am at least 21 years of age and was born on ________________. I, consequences of the procedure.
_________________________, hereby consent of my own free will to be
sterilized by Dr. ______________________________, by a method called Check the box or boxes below that apply.
____________________________________________________________. (1) At least 30 days have passed between the date of the individual's
My consent expires 180 days from the date of my signature below. signature on this consent form and the date sterilization was performed.
(2) This sterilization was performed less than 30 days but more than 72
I also consent to the release of this form and other medical records about this hours after the date of the individual's signature on this consent form because
operation to: representatives of MassHealth or employees of programs or of:
projects funded by MassHealth but only for determining if federal laws were a. Premature delivery. Expected date of delivery: ___________________
observed. b. Emergency abdominal surgery. Explain: ________________________
_______________________________________________________________
I have received a copy of this form.
Physician's Signature: _____________________________________
Signature: __________________________________ Date: _____________ Date: ________________________

Member ID: | | | | | | | | | | | | | Provider No.: | | | | | | | | | | |

You are requested to provide the following race and ethnicity information Interpreter's Statement
but it is not required. Check one block only. If an interpreter has assisted the individual considering sterilization, he or she
must complete and sign the following statement.
American Indian or Alaskan Native Hispanic
Asian or Pacific Islander White (not of Hispanic origin) I have translated the information and advice presented orally to the individual
Black (not of Hispanic origin)
considering sterilization by the person obtaining consent. I have also read to
Statement of Person Obtaining Consent
him or her the consent form in the following language, , and
Before ___________________________ signed the consent form, I
explained its contents to him or her. To the best of my knowledge and belief,
explained to him or her the nature of the sterilization operation,
she or he has understood this explanation.
___________________; the fact that it is intended to be a final and
irreversible procedure; and the discomforts, risks, and benefits associated Signature: __________________________________ Date: _______________
CS-21 (Rev. 05/09) Original to Patient, Copy to Physician, Completed Copy to Be Submitted with Claim