MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit

MO HealthNet Division 1

MO HealthNet Internet Provider Training Program

Presented by the Provider Education Unit MO HealthNet Division


Proper Completion of a Paper Sterilization Consent Form

Presented by theProvider Education UnitMO HealthNet Division


Procedure Codes That Require a Sterilization Consent Form

• 55250 – Vasectomy, unilateral or bilateral, including postoperative semen examination.

• 58565 – Hysteroscopy, Sterilization.• 58600 – Ligation or Transection of Fallopian tube(s),

abdominal or vaginal approach, unilateral or bilateral.

• 58605 – Ligation or Transection of Fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral.

• 58611 – Ligation/Transection-Fallopian tube(s) when done at same time as cesarean delivery.


Procedure Codes that Require a Sterilization Consent Form (Continued)

• 58615 – Occlusion of Fallopian tube(s) by device, (eg, Band, Clip, Falope Ring) vaginal or suprapubic approach.

• 58670 – Laproscopy, surgical; with fulguration of oviducts (with or without transection).

• 58671 – Laparoscopy, surgical; with occlusion of oviducts by device (eg, Band, Clip, or Falope Ring).



Doctor or Clinic


Name of Operation


Patient Name Physician Name

Participant Date of Birth

Participant Signature

Date (Month/day/year)

Method of Sterilization



Language of Interpreter

Signature of Interpreter Date (Month/Day/Year


Name of Individual

Name of Operation

Signature of Individual

Facility Name Facility Address

Date (Month/Day/Year)


Participant Name MO HealthNet ID Number

Date of Sterilization Name of Operation


Physician Signature

MO HealthNet Provider Identifier

Taxonomy Code

Date (Month/Day/Year)Describe Circumstances


• The MO HealthNet participant must be at least 21 years of age at the time consent is obtained. There are not exceptions (42 CFR 441.253).

• The MO HealthNet participant must not be a mentally incompetent individual or an institutionalized individual (42 CFR 441.251).

• The MO HealthNet participant must have voluntarily given informed consent.


Informed consent for a sterilization procedure may not be obtained from a

participant under the following conditions:

• The participant is in labor or childbirth.• The participant is seeking to obtain or is

obtaining an abortion.• The participant is under the influence of

alcohol or other substances that affect the individual’s state of awareness.


Exceptions to the Time Requirements for the Sterilization Consent Form

• Premature delivery: The Sterilization Consent Form must be completed and signed by the participant at least 72 hours prior to sterilization and at least 30 days prior to the expected date of delivery. Expected date of delivery is required on the Sterilization Consent Form.


Exceptions to the Time Requirements for the Sterilization Consent Form

• Emergency abdominal surgery: The Sterilization Consent Form must be completed and signed by the participant at least 72 hours prior to sterilization. The nature of the emergency abdominal surgery must be documented on the Sterilization Consent Form.


Obtaining a Copy of the Paper Form

To obtain a copy of the form, go to the MHD

public Web site,

www.dss.mo.gov/mhd/providers/index.htm.

In the left hand column, click on “MO HealthNet

Forms”. When the index of forms opens, click

on Sterilization Consent Form. You then can

print the form once it opens up on your

computer screen.


• You may either mail the completed Sterilization Consent Form to Infocrossing Healthcare Services, P.O. Box 5900, Jefferson City, MO 65102 or you may enter the information from this form via the Internet at www.emomed.com.


Thank you again for participating

in this training program. If you

have questions regarding the

information in this presentation,

please contact the Provider

Education Unit at 573-751-6683.

Documents

MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit