MO HealthNet Internet Provider

Training Program
Presented by the
Provider Education Unit
MO HealthNet Division
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Proper Completion of a Paper
Sterilization Consent Form

Presented by the
Provider Education Unit
MO HealthNet Division

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 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.
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 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).

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Doctor or Clinic

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Name of Operation

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 Participant Date Physician
Patient Name
of Birth Name

Method of Participant Date

Sterilization Signature (Month/day/year)

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 Language of Interpreter

Signature of Interpreter Date (Month/Day/Year

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 Name of Name of Date
Individual Operation (Month/Day/Year)

Signature of Facility Name Facility Address

Individual
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Participant Name MO HealthNet ID Number

Date of Sterilization Name of Operation

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 Describe Circumstances Date (Month/Day/Year)

Physician MO HealthNet Taxonomy Code

Signature Provider Identifier

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• 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.

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 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.

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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.

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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.

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 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.

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• 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.

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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.

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