Form F-01164 - Forwardhealth Sterilization Consent Form - Department Of Health Services - 2006
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Wis. Admin. Code § DHS 107.06(3)(e)
Division of Health Care Access and Accountability
F-01164 (10/08)
FORWARDHEALTH
CONSENT FOR STERILIZATION
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
13
I have asked for and received information about sterilization from
Before
signed the
1
_________________________________ . When I first asked for the
name of individual
consent form, I explained to him/her the nature of sterilization operation
doctor or clinic
14
information, I was told that the decision to be sterilized is completely up to
, the fact that it is
me. I was told that I could decide not to be sterilized. If I decide not to be
intended to be a final and irreversible procedure and the discomforts, risks
sterilized, my decision will not affect my right to future care or treatment. I
and benefits associated with it.
will not lose any help or benefits from programs receiving Federal funds,
I counseled the individual to be sterilized that alternative methods of
such as A.F.D.C. or Medicaid that I am now getting or for which I may
birth control are available which are temporary. I explained that steriliza-
become eligible.
tion 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withdrawn at any time and that he/she will not lose any health services or
DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR
any benefits provided by Federal funds.
CHILDREN OR FATHER CHILDREN.
To the best of my knowledge and belief the individual to be sterilized is
I was told about those temporary methods of birth control that are
at least 21 years old and appears mentally competent. He/She knowingly
available and could be provided to me which will allow me to bear or
and voluntarily requested to be sterilized and appears to understand the
father a child in the future. I have rejected these alternatives and chosen
nature and consequence of the procedure.
15
to be sterilized.
16
I understand that I will be sterilized by an operation known as a
2
Signature of person obtaining consent
Date
. The discomforts, risks
17
and benefits associated with the operation have been explained to me. All
Facility
of my questions have been answered to my satisfaction.
18
I understand that the operation will not be done until at least thirty days
Address
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 result in the
PHYSICIAN’S STATEMENT
withholding of any benefits or medical services provided by federally
Shortly before I performed a sterilization operation upon
funded programs.
3
I am at least 21 years of age and was born on __________________
19
20
on
.
Month
Day
Year
4
name of individual
date of sterilization
I,
, hereby consent of my own
I explained to him/her the nature of the sterilization operation
5
free will to be sterilized by
21
__________________________________________ , the fact that it is
doctor
6
by a method called
. My
specify type of operation
consent expires 180 days from the date of my signature below.
intended to be a final and irreversible procedure and the discomforts, risks
I also consent to the release of this form and other medical records
and benefits associated with it.
about the operation to:
I counseled the individual to be sterilized that alternative methods of
Representatives of the Department of Health and Human Services,
birth control are available which are temporary. I explained that steriliza-
or Employees of programs or projects funded by that Department
tion is different because it is permanent.
but only for determining if Federal laws were observed.
I informed the individual to be sterilized that his/her consent can be
withdrawn at any time and that he/she will not lose any health services or
I have received a copy of this form.
benefits provided by Federal funds.
7
8
__________________________________ Date: _______________
To the best of my knowledge and belief the individual to be sterilized is
Signature
Month Day Year
at least 21 years old and appears mentally competent. He/She knowingly
and voluntarily requested to be sterilized and appeared to understand the
You are requested to supply the following information, but it is not re-
nature and consequences of the procedure.
quired: (Ethnicity and Race Designation) (please check)
(Instructions for use of alternative final paragraphs: Use the first
Ethnicity:
Race (mark one or more):
paragraph below except in the case of premature delivery or emergency
Hispanic or Latino
American Indian or Alaska Native
abdominal surgery where the sterilization is performed less than 30 days
22
Not Hispanic or Latino
Asian
after the date of the individual’s signature on the consent form. In those
9
Black or African American
cases, the second paragraph below must be used. Cross out the para-
Native Hawaiian or Other Pacific
graph which is not used.)
Islander
(1) At least thirty days have passed between the date of the individual’s
White
signature on this consent form and the date the sterilization was
performed.
INTERPRETER’S STATEMENT
(2) This sterilization was performed less than 30 days but more than 72
hours after the date of the individual’s signature on this consent form
If an interpreter is provided to assist the individual to be sterilized:
because of the following circumstances (check applicable box and fill in
I have translated the information and advice presented orally to the
information requested):
Premature delivery
individual to be sterilized by the person obtaining this consent. I have also
10
23
24
read him/her the consent form in _______________________________
Individual’s expected date of delivery:
Emergency abdominal surgery (describe circumstances):
language and explained its contents to him/her. To the best of my
knowledge and belief he/she understood this explanation.
________________________________________________________
25
________________________________________________________
26
11
12
27
Interpreter’s Signature
Date
Physician’s Signature
Date
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