Form 193 "Alabama Medicaid Agency Sterilization Consent Form" - Alabama

What Is Form 193?

This is a legal form that was released by the Alabama Medicaid Agency - a government authority operating within Alabama. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on September 26, 2016;
  • The latest edition provided by the Alabama Medicaid Agency;
  • 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 193 by clicking the link below or browse more documents and templates provided by the Alabama Medicaid Agency.

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Download Form 193 "Alabama Medicaid Agency Sterilization Consent Form" - Alabama

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ALABAMA MEDICAID AGENCY STERILIZATION CONSENT FORM
NOTICE: YOUR DECISION AT ANY TIME TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITH HOLDING OF
ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
CONSENT TO STERILIZATION
STATEMENT OF PERSON OBTAINING CONSENT
I have asked for and received information about sterilization from
Before
Name of the Recipient
signed the consent form, I explained to him/her the nature of the
Physician or Clinic
sterilization operation
, the
Specify Type of Operation
When I first asked for the information, I was told that the decision to
fact that it is intended to be a final and irreversible procedure and the
be sterilized is completely up to me. I was told that I could decide not
discomforts, risks and benefits associated with it.
to be sterilized. If I decide not to be sterilized, my decision will not
I counseled the recipient to be sterilized that alternative methods
affect my right to future care or treatment. I will not lose any help or
of birth control are available which are temporary. I explained that
benefits from programs receiving Federal funds, such as Temporary
sterilization is different because it is permanent.
Assistance for Needy Families (TANF) or Medicaid that I am now
I informed the recipient to be sterilized that his/her consent can be
getting or for which I may become eligible.
withdrawn at any time and that he/she will not lose any health services
I UNDERSTAND THAT THE STERILIZATION MUST BE
or any benefits provided by Federal funds.
CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE
To the best of my knowledge and belief the recipient to be
DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR
sterilized is at least 21 years old and appears mentally competent.
CHILDREN OR FATHER CHILDREN.
He/She knowingly and voluntarily requested to be sterilized and
appears to understand the nature and consequence of the procedure.
I was told about those temporary methods of birth control that
X
X
are available and could be provided to me which will allow me to
Signature of Person Obtaining Consent
Date
bear or father a child in the future. I have rejected these
alternatives and chosen to be sterilized.
Type or Print Name
I understand that I will be sterilized by an operation known as a
Facility
Specify Type of Operation
Address
The discomforts, risks, and benefits associated with the operation
PHYSICIAN’S STATEMENT
have been explained to me. All my questions have been answered to
Shortly before I performed a sterilization operation upon
my satisfaction.
I understand that the operation will not be done until at least thirty
on
X
days after I sign this form. I understand that I can change my mind at
Name of the Recipient
Date of Sterilization
any time and that my decision at any time not to be sterilized will not
I explained to him/her the nature of the sterilization operation
result in the with-holding of any benefits or medical services provided
,
by federally funded programs.
Specify Type of Operation
I am at least 21 years of age and was born on
.
the fact that it is intended to be a final and irreversible procedure and
Month/Day/Year
the discomforts, risks and benefits associated with it.
I,
I counseled the recipient to be sterilized that alternative methods
Name of the Recipient
of birth control are available which are temporary. I explained that
sterilization is different because it is permanent.
hereby consent of my own free will to be sterilized by
I informed the recipient to be sterilized that his/her consent can be
withdrawn at any time and that he/she will not lose any health services
Physician or Clinic
or any benefits provided by Federal funds.
To the best of my knowledge and belief the recipient to be
by the method called
.
sterilized is at least 21 years old and appears mentally competent.
Specify Type of Operation
He/She knowingly and voluntarily requested to be sterilized and
appears to understand the nature and consequence of the procedure.
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
(Instructions for use of alternative final paragraphs: Use the
about this operation to: Representatives of the Department of Health
first paragraph below except in the case of premature delivery or
and Human Services or Employees of programs or projects funded by
emergency abdominal surgery where the sterilization is performed less
that Department but only for determining if Federal laws were
than 30 days after the date of the recipient’s signature on the consent
observed. I have received a copy of this form.
form. In those cases, the second paragraph below must be used.
Cross out the paragraph, which is not used.)
X
X
At least thirty days have passed between the date of the
(1)
Recipient’s Signature
Date
r ecipient’s signature on the consent form and the date the
sterilization was performed.
Type/Print Recipient’s Name
(2)
This sterilization was performed less than 30 days but more
than 72 hours after the date of the recipient’s signature on this
consent form because of the following circumstances (check
Recipient’s Medicaid Number
applicable box and fill in information requested):
INTERPRETER’S STATEMENT
 Premature delivery
Recipient’s expected date of delivery:
If an interpreter is provided to assist the recipient to be sterilized: I
 Emergency abdominal surgery
(describe circumstances in an
have translated the information and advice presented orally to the
attachment)
recipient to be sterilized by the person obtaining the consent. I have
X
X
also read him/her the consent form in
Physician’s Signature
Date
language and explained its contents to him/her. To the best of my
knowledge and belief, he/she understood this explanation.
Type/Print Name
NPI Number
Interpreter’s Signature
Date
Form 193 (Rev. 09-26-2016)
ALABAMA MEDICAID AGENCY STERILIZATION CONSENT FORM
NOTICE: YOUR DECISION AT ANY TIME TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITH HOLDING OF
ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
CONSENT TO STERILIZATION
STATEMENT OF PERSON OBTAINING CONSENT
I have asked for and received information about sterilization from
Before
Name of the Recipient
signed the consent form, I explained to him/her the nature of the
Physician or Clinic
sterilization operation
, the
Specify Type of Operation
When I first asked for the information, I was told that the decision to
fact that it is intended to be a final and irreversible procedure and the
be sterilized is completely up to me. I was told that I could decide not
discomforts, risks and benefits associated with it.
to be sterilized. If I decide not to be sterilized, my decision will not
I counseled the recipient to be sterilized that alternative methods
affect my right to future care or treatment. I will not lose any help or
of birth control are available which are temporary. I explained that
benefits from programs receiving Federal funds, such as Temporary
sterilization is different because it is permanent.
Assistance for Needy Families (TANF) or Medicaid that I am now
I informed the recipient to be sterilized that his/her consent can be
getting or for which I may become eligible.
withdrawn at any time and that he/she will not lose any health services
I UNDERSTAND THAT THE STERILIZATION MUST BE
or any benefits provided by Federal funds.
CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE
To the best of my knowledge and belief the recipient to be
DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR
sterilized is at least 21 years old and appears mentally competent.
CHILDREN OR FATHER CHILDREN.
He/She knowingly and voluntarily requested to be sterilized and
appears to understand the nature and consequence of the procedure.
I was told about those temporary methods of birth control that
X
X
are available and could be provided to me which will allow me to
Signature of Person Obtaining Consent
Date
bear or father a child in the future. I have rejected these
alternatives and chosen to be sterilized.
Type or Print Name
I understand that I will be sterilized by an operation known as a
Facility
Specify Type of Operation
Address
The discomforts, risks, and benefits associated with the operation
PHYSICIAN’S STATEMENT
have been explained to me. All my questions have been answered to
Shortly before I performed a sterilization operation upon
my satisfaction.
I understand that the operation will not be done until at least thirty
on
X
days after I sign this form. I understand that I can change my mind at
Name of the Recipient
Date of Sterilization
any time and that my decision at any time not to be sterilized will not
I explained to him/her the nature of the sterilization operation
result in the with-holding of any benefits or medical services provided
,
by federally funded programs.
Specify Type of Operation
I am at least 21 years of age and was born on
.
the fact that it is intended to be a final and irreversible procedure and
Month/Day/Year
the discomforts, risks and benefits associated with it.
I,
I counseled the recipient to be sterilized that alternative methods
Name of the Recipient
of birth control are available which are temporary. I explained that
sterilization is different because it is permanent.
hereby consent of my own free will to be sterilized by
I informed the recipient to be sterilized that his/her consent can be
withdrawn at any time and that he/she will not lose any health services
Physician or Clinic
or any benefits provided by Federal funds.
To the best of my knowledge and belief the recipient to be
by the method called
.
sterilized is at least 21 years old and appears mentally competent.
Specify Type of Operation
He/She knowingly and voluntarily requested to be sterilized and
appears to understand the nature and consequence of the procedure.
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
(Instructions for use of alternative final paragraphs: Use the
about this operation to: Representatives of the Department of Health
first paragraph below except in the case of premature delivery or
and Human Services or Employees of programs or projects funded by
emergency abdominal surgery where the sterilization is performed less
that Department but only for determining if Federal laws were
than 30 days after the date of the recipient’s signature on the consent
observed. I have received a copy of this form.
form. In those cases, the second paragraph below must be used.
Cross out the paragraph, which is not used.)
X
X
At least thirty days have passed between the date of the
(1)
Recipient’s Signature
Date
r ecipient’s signature on the consent form and the date the
sterilization was performed.
Type/Print Recipient’s Name
(2)
This sterilization was performed less than 30 days but more
than 72 hours after the date of the recipient’s signature on this
consent form because of the following circumstances (check
Recipient’s Medicaid Number
applicable box and fill in information requested):
INTERPRETER’S STATEMENT
 Premature delivery
Recipient’s expected date of delivery:
If an interpreter is provided to assist the recipient to be sterilized: I
 Emergency abdominal surgery
(describe circumstances in an
have translated the information and advice presented orally to the
attachment)
recipient to be sterilized by the person obtaining the consent. I have
X
X
also read him/her the consent form in
Physician’s Signature
Date
language and explained its contents to him/her. To the best of my
knowledge and belief, he/she understood this explanation.
Type/Print Name
NPI Number
Interpreter’s Signature
Date
Form 193 (Rev. 09-26-2016)