Free ForwardHealth Consent for Sterilization, F01164S - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1164A (10/08)

STATE OF WISCONSIN HFS 106.03(3)(e), Wis. Admin. Code

FORWARDHEALTH

CONSENT FOR STERILIZATION COMPLETION INSTRUCTIONS
ForwardHealth requires information to enable the programs to authorize and pay for medical services provided to eligible members. Members are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for the services. The use of this form is mandatory in order for ForwardHealth to reimburse providers for services. Any corrections to the form must be signed by the physician and/or member, as appropriate. The use of opaque correction fluids on the Consent for Sterilization form, F-1164 (also known as federal form HHS-687 [dated 11/06]) is prohibited. Instead, strike the incorrect information and initial the corrected information. CONSENT TO STERILIZATION The person who obtains the informed consent must provide orally all of the requirements for the informed consent as listed on the consent form, must offer to answer any questions, and must provide a copy of the consent form to the member to be sterilized for consideration during the waiting period. (The person obtaining consent need not be the physician performing the procedure.) Suitable arrangements must be made to ensure that the required information is effectively communicated to the member to be sterilized if he or she is blind, deaf, or otherwise handicapped. Element 1 -- Doctor or Clinic (required) The physician named in Element 1 is not required to match Elements 5 or 23. A member may receive information from one doctor/clinic and be sterilized by another. Corrections to this field must be initialed by the person obtaining consent or the physician. Element 2 -- Procedure (required) The information given in Element 2 must be comparable, but not necessarily identical, to Elements 6, 14, or 21. If the full name of the operation is provided in one of Elements 2, 6, 14, or 21, it is permissible to use an abbreviation for the other elements. Corrections to this field must be initialed by the member. Element 3 -- Date of Birth (required) Member's date of birth. The month, day, and year must be clearly indicated. Corrections to this field must be lined through and initialed by the member. (This correction does not require a new 30-day waiting period.) Element 4 -- Name of Member (required) The member's name must be legible. Initials are acceptable for the first and/or middle name only. The name may be typed. If this element does not match the signature in Element 7, check Wisconsin's Enrollment Verification System (EVS) to verify that this is the same person. Consider the name in Element 4 to be the valid name. Corrections to this field must be initialed by the member. (This correction does not require a new 30-day waiting period.) Element 5 -- Doctor (required) The name of the doctor, affiliates, or associates is acceptable. The physician in Element 5 is not required to match Element 1 or 23. Corrections to this element must be initialed by the person obtaining consent or the physician. (A consent form is transferable and does not necessitate a new 30-day waiting period.) Element 6 -- Procedure (required) The information given in Element 6 must be comparable, but not necessarily identical to Elements 2, 14, or 21. If the full name of the operation is provided in one of Elements 2, 6, 14, or 21, it is permissible to use an abbreviation for the other elements. Corrections to this field must be initialed by the member.

CONSENT FOR STERILIZATION COMPLETION INSTRUCTIONS F-1164A (10/08)

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Element 7 -- Signature (required) The member's signature does not need to exactly match the name in Element 4. It is unacceptable for the member's signature to be completely different from the name in Element 4. Initials are acceptable for the first and/or middle name. An "X" is acceptable as a signature if a witness of the member's choice has signed the form. The individual obtaining consent may not act as a witness. There is no field on the form for a witness' signature; it should appear directly below the member signature element and be followed by the date of witness, which must match the member's signature date in Element 8. Corrections to Element 7 must be initialed by the member. (A correction does not require a new 30-day waiting period.) Element 8 -- Date (required) The member must be at least 21 years old on this date. If the signature date is the member's 21st birthday, the claim is acceptable. At least 30 days but not more than 180 days, excluding the consent and surgery dates, must have passed between the date of the written informed consent and the date of sterilization, except in the case of premature delivery. Corrections to this field must be initialed by the member. (A correction does not require a new 30-day waiting period.) Element 9 -- Race and Ethnic Designation (not required) INTERPRETER'S STATEMENT An interpreter must be provided to assist the member if the member does not understand the language used on the consent form or the language used by the person obtaining the consent. Elements 10 to 12 -- Language, Interpreter, Date If applicable, the date the interpreter signs can be on or prior to the member's signature date in Element 8. STATEMENT OF PERSON OBTAINING CONSENT Element 13 -- Name of Member (required) The member's name does not need to exactly match the name in Element 4. Corrections to this field must be initialed by the member. (This correction does not require a new 30-day waiting period.) Element 14 -- Procedure (required) The information given in Element 14 must be comparable, but not necessarily identical, to Elements 2, 6, or 21. If the full name of the operation is provided in one of Elements 2, 6, 14, or 21, it is permissible to use an abbreviation for the other elements. Corrections to this field must be initialed by the member. Elements 15 to 18 -- Signature of Person Obtaining Consent, Date, Facility, Address (required) The person obtaining the consent may be, but is not required to be, the physician performing the procedure. A facility and/or facility address must be indicated, but only one (of the provider's choice) is required. Additionally, the signature date (Element 16) can be prior to, on, or after the date the member signs (Element 8). Corrections to this field must be initialed by the person obtaining consent. PHYSICIAN'S STATEMENT Element 19 -- Name of individual (required) The member's name does not need to exactly match the name in Element 4. Corrections to this field must be initialed by the member. (This does not require a new 30-day waiting period.) Element 20 -- Date of sterilization (required) The date must match the date of service (DOS) on the claim. Reimbursement is not allowed unless at least 30 days, but no more than 180 days, have passed between the date of informed consent and the date of the sterilization. This means the DOS must be at least the 31st day after the member signature date and no later than the 181st day after that date. Neither the date of informed consent nor the date of surgery will be counted as part of the 30-day requirement. In cases of premature delivery, the consent form must have been signed at least 30 days prior to the expected date of delivery as identified in Element 22 and at least 72 hours must have passed before premature delivery. In cases of emergency abdominal surgery, at least 72 hours must have passed from the date the member gave informed consent to be sterilized. Element 22 must be completed in the case of premature delivery or emergency abdominal surgery. Corrections to this field must be initialed by the physician. Note: Element 20 extends to the next line on the form.

CONSENT FOR STERILIZATION COMPLETION INSTRUCTIONS F- 1164A (10/08)

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Element 21 -- Specify type of operation (required) Must be comparable to Elements 2, 6, and 14 or state "same." If the full name of the operation is provided in one of Elements 2, 6, 14, or 21, it is permissible to use an abbreviation for the other elements. Corrections to this field must be initialed by the member. (This correction does not require a new 30-day waiting period.) Element 22 -- Exception to 30-Day Requirement (required if less than 31 days have passed between date of signed consent and sterilization date) The individual's expected date of delivery must be stated in the case of premature delivery. In the case of emergency abdominal surgery, the circumstances must be described. Corrections to this field must be initialed by the physician. Element 23 -- Physician's Signature and Date (required) · Alterations to this field must be initialed by the physician. · Initials may be used in the signature for the first and/or middle name only. · A signature stamp or computer-generated signature is not acceptable. · The physician's signature on the consent form does not need to exactly match the rendering physician's name on the claim form. It is unacceptable for the physician's signature to be completely different from the name on the claim. · Physician's signature date must be on or after the date the sterilization was performed. · A nurse or other individual's signature is not acceptable.