QUEST Integration – Sterilizations

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Informed Consent

Every patient must give voluntary, knowing consent and acknowledge receipt of the following information at least 30 days before the sterilization is performed:

• Advice that he/she may withdraw consent at any time without losing any entitled federally funded program benefits
• A description of alternative family planning methods
• Advice that the procedure is irreversible
• A thorough explanation of the specific surgical procedure
• A full description of the discomforts/risks, including an explanation of the type/possible effects of anesthesia
• A description of the benefits/advantages of sterilization
• Advice that the sterilization will not be performed until at least 30 days after he/she signs the consent form and not more than 180 days
• An offer to answer any questions concerning the procedure

The patient must meet requirements in accordance with HRS Section 560:5-601-612 in order for consent to be obtained from a guardian under certain situations.

Informed consent may not be obtained while the individual is:

• In labor or childbirth
• Obtaining or seeking to obtain an abortion. This does not prevent you from performing a sterilization and abortion at the same time as long as the patient was not known to be pregnant when the consent form was signed
• Under the influence of substances that affect the person’s state of awareness

Patient Acknowledgment

Patients must acknowledge receipt of the above information by signing the Sterilization Required Consent Form 1146 at least 30 days before the procedure is done. No substitutions of the form are acceptable. The patient must be given a copy of the form with all information completed, except the Physician Statement Section, which is completed by the surgeon after the procedure is done. All spaces for names, dates, procedures and other information must be completed even if the information is repeated on different parts of the form.

Interpreters must be provided to ensure the required information is understood clearly by those with special communication needs, including those with physical handicaps and those not proficient in English.

Time Restrictions

The form must be signed and dated by the patient a minimum of 30 days before the procedure is done. Consent expires 180 days after it is given.

In the event of premature delivery or emergency abdominal surgery resulting in a sterilization less than 30 days from the consent date, the expected date of delivery or the emergency circumstances must be provided on the Form 1146. The expected date of delivery must be at least 30 days from the consent date, and the provider must certify that the procedure was done at least 72 hours after the consent was given.

Exclusions to Consent Form Requirement

Removal of a single remaining fallopian tube due to an ectopic pregnancy, and vasectomy in association with a prostatectomy or other urinary tract surgery to prevent epididymitis are not considered primary sterilization procedures. The consent form is not required. These medical conditions must be clearly identified on claims.

Ineligible Sterilizations

• Sterilizations for institutionalized patients
• Sterilizations for patients younger than 21 at the time of consent, even if the patient will be 21 at the time of the procedure
• Sterilizations for patients judged mentally incompetent to comprehend the significance of the procedure and thus give informed consent

Consent Form Requirement

• Pre-certification is not required for sterilizations; however, the Sterilization Required Consent Form 1146 must be signed in a timely manner. Effective 7/1/2020 the Med-QUEST Division (MQD) is transitioning to the federal from HHS 687- Consent for Sterilization from the DHS 1146- Sterilization Required Consent From. Effective 01/01/2021 only the HHS 687 will be accepted.
• The form must be fully completed with all fields filled in even if they are repetitive:
• Patient information includes the patient’s full name, date of birth, QUEST Integration member number, the method of sterilization, patient’s signature and date the form was signed.
• If an interpreter was used, indicate the language, dialect or method of interpretation. The interpreter must sign and date the form at the same time the patient does as interpretation of the required information must be done before the patient signs.
• The person who obtained the patient’s consent after giving the patient the required sterilization information and answering his/her questions must sign and date the form. The person need not be a physician but must have adequate background to answer questions properly.
• The surgeon must complete the Physician’s Statement portion after the sterilization is done certifying that before pre-medicating the patient, the patient again was counseled and given the required sterilization information. The sterilization must have been performed at least 30 days from the date the patient signed the form. If less than 30 days had elapsed, the reason for not meeting the waiting period must be checked in the appropriate area of the form. In cases of premature delivery, the expected date of delivery must be at least 30 days from the date the form was signed by the member. In cases of emergency abdominal surgery, the emergency must be described and must be at least 72 hours from the date signed.

Claim Form Requirements

Attach a copy of the signed consent form to the claim. Surgeons must make copies of the form available to all providers involved in the surgery, including co-surgeons, anesthesiologists and hospitals so that their claims may be submitted with a copy of the form. Claims for sterilizations in which there is no record of a properly signed consent form will be denied.

Revision History