Instructions for Form MED-178 "Sterilization Consent Form" - Colorado

This document contains official instructions for Form MED-178, Sterilization Consent Form - a form released and collected by the Colorado Department of Public Health and Environment.

Instruction Details:

  • This 3-page document is available for download in PDF;
  • Actual and applicable for the current year;
  • Complete, printable, and free.

Download your copy of the instructions by clicking the link below or browse hundreds of other forms in our library of forms released by the Colorado Department of Public Health and Environment.

ADVERTISEMENT
ADVERTISEMENT

Download Instructions for Form MED-178 "Sterilization Consent Form" - Colorado

117 times
Rate (4.8 / 5) 8 votes
Sterilization Consent Form (Med-178) Instructions and Guidance
Following is the list of fields included in the consent form requirements for sterilization. All fields are required to be
completed except Field #9 (race/ethnicity) which is optional, Fields #10-12 which only need to be completed if an
interpreter was used, and Field #24 which is conditional. Entries in all fields must be legible – if signatures are not legible,
please print the name nearby. Any corrections to the client’s portion of the sterilization consent must be approved and
initialed by the client; however, many fields in the client’s portion may be pre-filled or stamped. Fields #7 and #8 in
bold print cannot be altered. Once an error is made in these fields, the consent form cannot be resubmitted.
Completion
Field
Description
Format
Instructions
ID
Client’s
7 characters
Client’s seven-figure alphanumeric Medicaid ID#.
Colorado
Required
Medicaid ID
CONSENT TO STERILIZATION (Client’s Portion)
1.
Health Care
Text
Name of the health care provider, group, or clinic that is providing
Provider or
Required
client with information about sterilization. May be pre-filled,
Clinic
stamped, or written.
2.
Type of
Text
Name of procedure. Must be consistent throughout form (Fields 2, 6,
Procedure
Required
14, and 20). For women, it is acceptable to note “tubal sterilization”
in all fields. May be pre-filled, stamped, or written.
3.
Date of Birth
6 digits
Client’s date of birth (MM/DD/YY). Must match the date of birth on
Required
the claim. Client must be at least 21 years old on the date that
consent is signed by client.
4.
Client’s Name
Text
Client’s name. Must be consistent throughout form (Fields 4, 13, and
Required
18) and must match name on claim and/or eligibility inquiry.
5.
Health Care
Text
Name of the health care provider, group, or clinic that is expected to
Provider or
Required
perform the procedure. Note: If an individual provider is listed in
Clinic
Field 5, but the name does not match the signature in Field 22, then
Field 24 must be completed. May be pre-filled, stamped, or written.
If the clinic name is listed in Field 5, then Field 24 does not need to be
completed.
6.
Type of
Text
Name of procedure. Must be consistent throughout form (Fields 2, 6,
Procedure
Required
14, and 20). For women, it is acceptable to note “tubal sterilization”
in all fields. May be pre-filled, stamped, or written.
7.
Client’s
Text
Client’s signature cannot be altered, traced over, or corrected. It is
Signature for
Required
not acceptable to enter initials only. If the signature is not legible,
Consent to
the client’s name should be printed under the signature.
Sterilization
8.
Date of
6 Digits
Date consent form was signed by client (MM/DD/YY). Client must
Client’s
Required
be at least 21 years old on this date. At least 30 days (but no more
Signature
than 180 days) must have passed between this date and the date
the sterilization procedure is performed. The 30-day count begins
the day after the date of client’s signature.
9.
Race/Ethnicity
Check
This field is optional.
box
INTERPRETER’S STATEMENT
10.
Language
Text
Language used in counseling the client, if other than English or
Conditional
Spanish (see Spanish form). Otherwise, leave blank.
11.
Interpreter’s
Text
Signature of interpreter if interpreter was used. Otherwise, leave
Signature
Conditional
blank.
Revised: 10/13
Sterilization Consent Form (Med-178) Instructions and Guidance
Following is the list of fields included in the consent form requirements for sterilization. All fields are required to be
completed except Field #9 (race/ethnicity) which is optional, Fields #10-12 which only need to be completed if an
interpreter was used, and Field #24 which is conditional. Entries in all fields must be legible – if signatures are not legible,
please print the name nearby. Any corrections to the client’s portion of the sterilization consent must be approved and
initialed by the client; however, many fields in the client’s portion may be pre-filled or stamped. Fields #7 and #8 in
bold print cannot be altered. Once an error is made in these fields, the consent form cannot be resubmitted.
Completion
Field
Description
Format
Instructions
ID
Client’s
7 characters
Client’s seven-figure alphanumeric Medicaid ID#.
Colorado
Required
Medicaid ID
CONSENT TO STERILIZATION (Client’s Portion)
1.
Health Care
Text
Name of the health care provider, group, or clinic that is providing
Provider or
Required
client with information about sterilization. May be pre-filled,
Clinic
stamped, or written.
2.
Type of
Text
Name of procedure. Must be consistent throughout form (Fields 2, 6,
Procedure
Required
14, and 20). For women, it is acceptable to note “tubal sterilization”
in all fields. May be pre-filled, stamped, or written.
3.
Date of Birth
6 digits
Client’s date of birth (MM/DD/YY). Must match the date of birth on
Required
the claim. Client must be at least 21 years old on the date that
consent is signed by client.
4.
Client’s Name
Text
Client’s name. Must be consistent throughout form (Fields 4, 13, and
Required
18) and must match name on claim and/or eligibility inquiry.
5.
Health Care
Text
Name of the health care provider, group, or clinic that is expected to
Provider or
Required
perform the procedure. Note: If an individual provider is listed in
Clinic
Field 5, but the name does not match the signature in Field 22, then
Field 24 must be completed. May be pre-filled, stamped, or written.
If the clinic name is listed in Field 5, then Field 24 does not need to be
completed.
6.
Type of
Text
Name of procedure. Must be consistent throughout form (Fields 2, 6,
Procedure
Required
14, and 20). For women, it is acceptable to note “tubal sterilization”
in all fields. May be pre-filled, stamped, or written.
7.
Client’s
Text
Client’s signature cannot be altered, traced over, or corrected. It is
Signature for
Required
not acceptable to enter initials only. If the signature is not legible,
Consent to
the client’s name should be printed under the signature.
Sterilization
8.
Date of
6 Digits
Date consent form was signed by client (MM/DD/YY). Client must
Client’s
Required
be at least 21 years old on this date. At least 30 days (but no more
Signature
than 180 days) must have passed between this date and the date
the sterilization procedure is performed. The 30-day count begins
the day after the date of client’s signature.
9.
Race/Ethnicity
Check
This field is optional.
box
INTERPRETER’S STATEMENT
10.
Language
Text
Language used in counseling the client, if other than English or
Conditional
Spanish (see Spanish form). Otherwise, leave blank.
11.
Interpreter’s
Text
Signature of interpreter if interpreter was used. Otherwise, leave
Signature
Conditional
blank.
Revised: 10/13
12.
Date of
6 Digits
Date that interpreter signed consent form (MM/DD/YY), if interpreter
Interpreter’s
Conditional
was used. Otherwise, leave blank.
Signature
STATEMENT OF PERSON OBTAINING CONSENT
13.
Client’s Name
Text
Client’s name. Must be consistent throughout form (Fields 4, 13, and
Required
18) and must match name on claim and/or eligibility inquiry.
14.
Type of
Text
Name of procedure. Must be consistent throughout form (Fields 2, 6,
Procedure
Required
14, and 20). For women, it is acceptable to note “tubal sterilization”
in all fields. May be pre-filled, stamped, or written.
15.
Signature of
Text
Signature of person obtaining consent. May be practitioner,
Person
Required
practitioner’s designee, or staff.
Obtaining
Consent
16.
Date of
6 Digits
Date that person obtaining consent signed consent form
Signature of
Required
(MM/DD/YY).
Person
Obtaining
Consent
17.
Facility Name
Text
Name and address (street address, city, state, zip) of office or facility
and
Required
where client was given information about sterilization/where consent
Facility
was obtained. This is not necessarily the facility where procedure will
Address
take place, but it can be. May be pre-filled, stamped, or written.
PHYSICIAN’S STATEMENT
18.
Client’s Name
Text
Client’s name. Must be consistent throughout form (Fields 4, 13, and
Required
18) and must match name on claim and/or eligibility inquiry.
19.
Date
6 Digits
Date sterilization procedure was performed (MM/DD/YY). This date
Sterilization
Required
must be at least 30 days but no more than 180 days from the date
Procedure was
the client signed consent form (Field 8). The date the client signed
Performed
the consent form and the date of the procedure are not counted as
part of the 30-day requirement. Date of the procedure can be the
st
31
day after the date of client’s consent signature, or later (but no
st
later than 181
day). Exceptions to 30-day requirement below (Field
21). Date must match date of service on claim.
20.
Type of
Text
Name of procedure. Must be consistent throughout form (Fields 2, 6,
Procedure
Required
14, and 20). However, for women, if “tubal sterilization” is listed in all
other fields, a more specific tubal procedure may be listed here (e.g.,
tubal ligation, tubal occlusion, Essure procedure).
21(1).
Alternative
Required
Paragraph 1: If at least 30 days, but no more than 180 days have
Final
passed between the date of the client’s signature and the date the
Paragraph 1
procedure was performed, then Alternative Paragraph 2 should be
crossed out.
21(2).
Alternative
Required
Paragraph 2: If 30 days have not passed, but at least 72 hours have
Final
passed from when the client signed the consent form, then
Paragraph 2
Alternative Paragraph 1 should be crossed out.
21(2a)
Alternative
Conditional
Paragraph 2a: If Alternative Paragraph 2 is not crossed out, and the
Final
Check
reason is because of premature delivery, then check this box and
Paragraph 2a
Box
indicate the client’s expected date of delivery. If the client’s
expected date of delivery is not at least 31 days from the date of the
client’s signature and this box is checked, the consent will not be
considered as valid.
Revised: 10/13
21(2b)
Alternative
Conditional
Paragraph 2b: If Alternative Paragraph 2 is not crossed out, and the
Final
Check
reason is because of emergency abdominal surgery, then check this
Paragraph 2b
box
box and list the name of the surgical procedure and describe the
circumstances for the emergency abdominal surgery.
22.
Signature of
Text
The person who actually performed the sterilization procedure must
Person Who
Required
sign the form after the procedure is performed. A signature stamp is
Performed
not acceptable. If the signature is not legible, print the doctor’s
Sterilization
name below the signature line. If an individual practitioner is listed in
Procedure
field 5 but that name does not match the signature in Field 22, then
Field 24 must be completed.
23.
Date of
6 digits
Date of doctor’s signature (MM/DD/YY). Date must be on or after
Signature of
Required
the date of the sterilization procedure.
Person Who
Performed
Sterilization
Procedure
24.
Different
Text
If an individual practitioner’s name is listed in Field 5 (rather than a
Practitioner
Conditional
group or clinic name), and that practitioner’s name is different from
Performed
the signature in Field 22, provide an explanation for the difference.
Procedure
Check the boxes to indicate the reason for the difference:
• A different practitioner was on call at time of procedure
• A different practitioner in the same practice did the procedure
• Other, please explain
Revised: 10/13
Page of 3