Commonwealth of Massachusetts  •  Executive Office of Health and Human Services
Sterilization Consent Form (Ages 18 - 20)

Notice: Your decision at any time not to be sterilized will not result in the withdrawal or withholding of any benefits provided by programs or projects receiving federal funds.	

Consent to Sterilization
I have asked for and received information about sterilization from ________ ____________ (physician or clinic). When I first asked for the information, I was told that the decision to be sterilized was completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving federal funds, such as AFDC or MassHealth that I am now getting or for which I may become eligible.

I understand the sterilization must be considered permanent and not reversible.  I have decided that I do not want to become pregnant, bear children, or father children.  

I was told about those temporary methods of birth control that are available and could be provided to me that will allow me to bear or father a child in the future.  I have rejected these alternatives and have chosen to be sterilized.

I understand that I will be sterilized by an operation known as a _________________________________.  The discomforts, risks, and benefits associated with the operation have been explained to me.  All my questions have been answered to my satisfaction.

I understand that the operation will not be done until at least 30 days after I sign this form.  I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs.

I am between 18 and 20 years of age and was born on _________________. I, ____________________________, hereby consent of my own free will to be sterilized by Dr. ________________________, by a method called ____________________________________________________________.
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 about this operation to: representatives of  MassHealth or employees of programs or projects funded by MassHealth but only for determining if federal laws were observed.

I have received a copy of this form.

Signature: __________________________________ Date: _____________ 

Member ID: |      |      |      |      |      |      |      |      |      |      |      |      |

You are requested to provide the following race and ethnicity information but it is not required.  Check one block only.

 American Indian or Alaskan Native		 Hispanic 
 Asian or Pacific Islander 			 White (not of Hispanic origin)
 Black (not of Hispanic origin)
Statement of Person Obtaining Consent
Before ___________________________ signed the consent form, I explained to him or her the nature of the sterilization operation, ___________________; the fact that it is intended to be a final and irreversible procedure; and the discomforts, risks, and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available that are temporary.  I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that he or she may withdraw consent at any time and that he or she will not lose any health services or any benefits provided by federal funds.

To the best of my knowledge and belief, the individual to be sterilized is at least 18 years old and appears mentally competent. He or she knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure.
Signature: __________________________________ Date: ______________ 
Facility: _______________________________________________________ 
Address: _______________________________________________________ 
	Physician's Statement 
Shortly before I performed a sterilization upon _________________________ (name of member) on ___________________ (date), I explained to him or her the nature of the sterilization operation known as _______________________; the fact that it is intended to be a final and irreversible procedure; and the discomforts, risks, and benefits associated with it.  I counseled the individual to be sterilized that alternative methods of birth control are available that are temporary.  I explained that sterilization is different because it is permanent.  I informed the individual to be sterilized that he or she may withdraw consent at any time and that he or she will not lose any health services or benefits provided by federal funds.

To the best of my knowledge and belief, the individual to be sterilized is at least 18 years old and appears mentally competent.  He or she knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure.

Check the box or boxes below that apply.
 (1) At least 30 days have passed between the date of the individual's signature on this consent form and the date sterilization was performed.
 (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of:
      a. Premature delivery. Expected date of delivery: ___________________ 
      b. Emergency abdominal surgery. Explain: ________________________ 
_______________________________________________________________ 
Physician's Signature: _____________________________________
Date: ________________________ 

Provider No.: |      |      |      |      |      |      |      |      |      |      |     

Interpreter's Statement
If an interpreter has assisted the individual considering sterilization, he or she must complete and sign the following statement. 

I have translated the information and advice presented orally to the individual considering sterilization by the person obtaining consent.  I have also read to him or her the consent form in the following language,                            , and explained its contents to him or her.  To the best of my knowledge and belief, she or he has understood this explanation.

Signature: __________________________________ Date: _______________