Author: GDIT, (800) 688-6696
The sterilization consent form found on the U.S. Department of Health & Human Services (HHS) website has been updated. The routine Office of Management and Budget (OMB) consent form review process has finalized, and the only change made to the form was the new expiration date of April 30, 2022. Providers should now use this version when submitting the sterilization consent form to the NC Medicaid fiscal agent.
NC Medicaid has been informed that providers are obtaining patient consent for sterilization on this final approved sterilization consent form (exp. date April 30, 2022) with backdating of signatures to a date prior to the new form effective date of May 1, 2019. This is not acceptable and will result in denials.
Links to latest approved consent form:
https://www.hhs.gov/opa/sites/default/files/consent-for-sterilization-english-updated.pdf (English)
https://www.hhs.gov/opa/sites/default/files/consent-for-sterilization-spanish-updated.pdf (Spanish)
These links can also be accessed from the NC Medicaid website: https://medicaid.ncdhhs.gov/forms. Providers can access the Sterilization Consent Form by clicking on the Sterilization link and then on the words “Sterilization Consent Form.”
Providers may choose to complete the form for each individual or pre-populate information on the site prior to printing the consent form. Signature fields may not be pre-populated. Providers will be notified if a change occurs to the sterilization consent form prior to the expiration date of April 30, 2022. Providers with questions can contact the GDIT Call Center at (800)-688-6696 or NCTracksprovider@nctracks.com.