Sterilization Consent Form

Providers were notified in the August Medicaid Bulletin that as of May 1, 2019, the sterilization consent form was updated with an expiration date of April 30, 2022. The sterilization consent form found on the U.S. Department of Health & Human Services (HHS) website has been updated. Providers should now be using this version when submitting the sterilization consent form to the NC Medicaid fiscal agent. 

Providers are still obtaining signatures of consent on sterilization forms that are outdated with expiration dates prior to April 30, 2022.  Effective Nov. 1, 2019, NC Medicaid will only accept new signatures of consent on the latest version of the consent form with expiration date of April 30, 2022. Therefore, consent forms with a beneficiary signature after Oct. 31, 2019 on an expired consent form will receive a permanent denial. Backdating of signatures on the latest version to a date prior to the new form effective date of May 1, 2019 is not acceptable and will also result in a permanent denial.

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. 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.