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20.7.9.2 Required Fields
All of the fields must be legible in order for the consent form to be valid. Any illegible field results in a denial of the submitted consent form. Resubmission of legible information must be indicated on the consent form itself. Resubmission with information indicated on a cover page or letter is not accepted.
Consent to Sterilization
• Name of doctor or clinic.
•Name of the sterilization operation.
•Client's date of birth (month, day, year).
•Client's name (first and last names are required).
•Client's signature.
•Date of client signature-Client must be 21 years of age or older on this date. This date cannot be altered or added at a later date.
Interpreter's Statement (If Applicable)
•Name of language used by interpreter.
•Interpreter's signature.
•Date of interpreter's signature (month, day, year).
Statement of Person Obtaining Consent
•Client's name (first and last names are required).
•Name of the sterilization operation.
•Signature of person obtaining consent-The statement of person obtaining consent must be completed by the person who explains the surgery and its implications and alternate methods of birth control. The signature of person obtaining consent must be completed at the time the consent is obtained. The signature must be an original signature, not a rubber stamp.
•Date of the person obtaining consent's signature (month, day, year)-Must be the same date as the client's signature date.
•Facility name-Clinic/office where the client received the sterilization information.
•Facility address-Clinic/office where the client received the sterilization information.
Physician's Statement
•Client's name (first and last names are required).
•Date of sterilization procedure (month, day, year)- Must be at least 30 days and no more than 180 days from the date of the client's consent except in cases of premature delivery or emergency abdominal surgery.
•Name of the sterilization operation.
•Expected date of delivery (EDD)-Required when there are less than 30 days between the date of the client consent and date of surgery. Client's signature date must be at least 30 days prior to EDD.
•Circumstances of emergency surgery-Operative report(s) detailing the need for emergency abdominal surgery are required.
•Physician's signature-Stamped or computer-generated signatures are not acceptable.
•Date of physician's signature (month, day, year)-This date must be on or after the date of surgery.
Paperwork Reduction Act Statement
This is a required statement and must be included on every Sterilization Consent Form submitted.
Additional Required Fields
•The following provider identification numbers are required to expedite the processing of the consent form:
•Texas Provider Identifier (TPI).
•National Provider Identifier (NPI).
•Taxonomy.
•Benefit code.
•Provider/clinic phone number.
•Provider/clinic fax number (If available).
•Family planning title for client-Indicated by circling V, X, XIX, or XX.
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