MO HealthNet Internet Provider Training Program

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• 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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Physician Name
Participant Date of Birth
Patient Name
Participant Signature
Date (Month/day/year)
Method of Sterilization
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Language of Interpreter
Signature of Interpreter
Date (Month/Day/Year
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Name of Individual
Name of Operation
Date (Month/Day/Year)
Signature of Individual
Facility Name
Facility Address
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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 Signature
MO HealthNet Provider Identifier
Taxonomy Code
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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 individuals
  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.