Form FA-56 "Sterilization Consent Form" - Nevada

What Is Form FA-56?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 31, 2020;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FA-56 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form FA-56 "Sterilization Consent Form" - Nevada

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Sterilization Consent Form
Sterilization Consent Form
Recipient’s Statement
I have asked for and received information about sterilization from_____________________________________________.
(Physician or Clinic Name)
When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I
could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or
treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I
am now getting or for which I may become eligible.
I understand that the sterilization must be considered permanent and not reversible. I have decided that I do not want to
become pregnant, bear children or father children.
I was told about those temporary methods of birth control that are available and could be provided to me which will allow
me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized.
I understand that I will be sterilized by an operation known as a _______________________________________________.
The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been
answered to my satisfaction.
I understand that the operation will not be done until at least 30 days after I sign this form. I understand that I can
change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any
benefits or medical services provided by Federally funded programs.
I am at least 21 years of age and was born on _______________________. (Month-Day-Year)
I, ________________________________________________, hereby consent of my own free will to be sterilized by
__________________________________________________ by a method called ________________________________.
(Physician Name)
My consent expires 180 days from the date of my signature below.
I also consent to the release of this form and other medical records about the operation to: Representatives of the
Department of Health and Human Services or Employees of programs or projects funded by that Department but only for
determining if Federal laws were observed.
I have received a copy of this form.
Signature:
________________________________________________
Date:
__________________________
(Month-Day-Year)
You are requested to supply the following information, but it is not required:
Race and ethnicity designation (please check)
Black (not of Hispanic origin)
American Indian or Alaskan Native
Hispanic
White (not of Hispanic origin)
Asian or Pacific Islander
Updated 03/31/2020
FA-56 Sterilization Consent Form
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Sterilization Consent Form
Sterilization Consent Form
Recipient’s Statement
I have asked for and received information about sterilization from_____________________________________________.
(Physician or Clinic Name)
When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I
could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or
treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I
am now getting or for which I may become eligible.
I understand that the sterilization must be considered permanent and not reversible. I have decided that I do not want to
become pregnant, bear children or father children.
I was told about those temporary methods of birth control that are available and could be provided to me which will allow
me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized.
I understand that I will be sterilized by an operation known as a _______________________________________________.
The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been
answered to my satisfaction.
I understand that the operation will not be done until at least 30 days after I sign this form. I understand that I can
change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any
benefits or medical services provided by Federally funded programs.
I am at least 21 years of age and was born on _______________________. (Month-Day-Year)
I, ________________________________________________, hereby consent of my own free will to be sterilized by
__________________________________________________ by a method called ________________________________.
(Physician Name)
My consent expires 180 days from the date of my signature below.
I also consent to the release of this form and other medical records about the operation to: Representatives of the
Department of Health and Human Services or Employees of programs or projects funded by that Department but only for
determining if Federal laws were observed.
I have received a copy of this form.
Signature:
________________________________________________
Date:
__________________________
(Month-Day-Year)
You are requested to supply the following information, but it is not required:
Race and ethnicity designation (please check)
Black (not of Hispanic origin)
American Indian or Alaskan Native
Hispanic
White (not of Hispanic origin)
Asian or Pacific Islander
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FA-56 Sterilization Consent Form
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Sterilization Consent Form
Sterilization Consent Form
Interpreter's Statement
If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice
presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the
consent form in ______________________________ language and explained its contents to him/her. To the best of my
knowledge and belief he/she understood this explanation.
Interpreter Signature:
__________________________________________
___ Date:
__________
Statement of Person Obtaining Consent
Before ____________________________________ signed the consent form, I explained to him/her the nature of the
(Name of Individual)
sterilization operation ________________________________, the fact that it is intended to be a final and irreversible
procedure and the discomforts, risks and benefits associated with it.
I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I
explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her
consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by
Federal funds.
To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally
competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and
consequence of the procedure.
Signature of Person Obtaining Consent: _____________________________________ Date:
______________
Facility Name:
____________________________________________
Address: _______________________________________________________________________________________
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Sterilization Consent Form
Sterilization Consent Form
Physician's Statement
Shortly before I performed a sterilization operation upon
_______________________________________________ on_________________________, I explained to him/her the
(Name of Individual Sterilized)
(Date of Sterilization Operation)
nature of the sterilization operation __________________________________, the fact that it is intended to be a final and
(Specify Type of Operation)
irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized
that alternative methods of birth control are available which are temporary. I explained that sterilization is different
because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and
that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and
belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and
voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure.
Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature
delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the
individual's signature on the consent form. In those cases, the second paragraph below must be used.
Cross out the paragraph which is not used.
1) At least 30 days have passed between the date of the individual's signature on this consent form and the date
the sterilization was performed.
2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's
signature on this consent form because of the following circumstances (check applicable box and fill in
information requested):
Premature delivery. Individual's expected date of delivery:
__________________________________
Emergency abdominal surgery. (Describe circumstances.):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Physician Signature:
_________________________________________
Date:
_________________________
Physician Name (please print): _________________________________________________
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