Ga. Medicaid Part II Policies & Procedures for Hospital Services, Appendix H

The Division will make reimbursement only for those sterilization procedures, which meet the criteria established

in Section 911.2 of this manual. A copy of the “Informed Consent for Voluntary Sterilization” (Form DMA-69) is

attached as Pages K-3 and K-4 of this Appendix. The member and the attending physician must properly

complete this form on both sides.

A. Some important points in obtaining and submitting a properly executed Form DMA-69 are listed

below.

i. Under the physician’s statement:

1. The applicable paragraph, (a) or (b) must be designated. (a) States “At least 30

days have passed between the date of the individual’s signature on this consent

form and the date the sterilization was performed”.

2. States “At least 30 days have passed between the date of the individual’s

signature on this consent form and the date the sterilization was performed”.

3. States “This sterilization was performed less than 30 days but more than 72 hours

after the date of the individual’s signature on the consent form because of the

following circumstances.”

4. If (b) is designated, the applicable box must be checked and the information

requested must be filled in.

5. If the box indicating “Premature delivery” is checked, the individual’s date of

expected delivery must be given on the line provided.

6. If the box indicating “Emergency abdominal surgery” is checked, the

circumstances of the emergency surgery must be described on the line provided.

7. The physician must sign and date the consent form after the surgery is performed.

8. The physician must sign and date the consent form. Signature stamps are not

acceptable.

9. All lines on the consent form must be completed, with the exception of the

interpreter’s statement. The interpreter’s statement does not need to be completed

unless a language other than English was used to explain the sterilization

procedure to the member.

10. The method used by the Division to calculate the 30-day wait is: Begin counting

with the first day after the day the member signs the consent form and count

forward 30 days. The sterilization may be performed as early as the 30th day.

11. The only consent form acceptable to the Division is: “Informed Consent for

Voluntary Sterilization” (DMA-69). No other form can be used.

12. The sterilization informed consent form may not be used for hysterectomy

procedures. Medically necessary hysterectomy procedures require the “Patient’s

Acknowledgement of Prior Receipt of Hysterectomy Information” form (DMA-

276).

13. Using a generic description and not a specific physician’s name is acceptable on

line seven (7) of the sterilization consent form when it is not known in advance

which specific physician will perform the procedure. The members must be

informed that the procedure will be performed by the physician on-call or on

duty at the time. The name of the provider (hospital, physicians’ group, surgical

center, or whomever) should also be entered on line seven (7) of the sterilization

consent form.

14. A copy of the properly executed “Informed Consent for Voluntary Sterilization”

form must be attached to all claims for services rendered in conjunction with the

sterilization when submitted to the Division for payment.

15. NOTE: Medicaid funds are unavailable for sterilization, hysterectomies, or

abortions performed without the documentation required by federal regulations

(See 42 CFR 441.206 and 441.256). As such, claims for payment submitted

without the required documentation or with incomplete or inaccurate

documentation will be denied. The Division does not accept documentation

meant to satisfy informed consent requirements which have been completed or

altered after the service was performed.

CONSENT FOR VOLUNTARY STERILIZATION (DMA-69)

This federally mandated form may be submitted online or as a hard copy. When submitting the hard copy, you

must complete both sides and submit it with all claims for sterilization. Review Part II, Chapter 900 of the

Policies and Procedures for Hospital Services manual for details on completion of the form. Review blanks and

dates on the form to verify age requirements, time lapse, and signature fields (use black ink).

Completion Of the Informed Consent for Voluntary Sterilization (DMA-69)

The DMA will reimburse providers only for the sterilization procedures, which meet the criteria,

established in Part II, Chapter 900 of the Policies and Procedures for Hospital Services manual.

The recipient and the attending physician must properly complete this form on both sides.

Consent to Sterilization:

Physician or Clinic:

Enter the name of the physician performing the sterilization process.

Sterilization Procedure:

Enter the medical name of the sterilization procedure.

Birth date:

Enter month, day, and year of the member’s birth.

Name of Member:

Print the name of the member

Name of Physician:

Print the name of the physician performing the sterilization procedure.

Sterilization Procedure:

Enter the medical name of the sterilization procedure.

Signature of Medicaid Member:

The Medicaid member must sign the consent form. This field cannot be changed or clarified.

Date Signed:

Enter the date that the Medicaid member signed the consent form. This field cannot be changed

or clarified and must match date witness signed and dated.

Race and Ethnicity Designation:

the member is requested to supply the race and ethnicity designation, but it is not required. Please

check if you elect to do so.

Interpreter’s Statement

If the member is not knowledgeable of the English language or is unable to read the Consent to

Sterilization, an interpreter must be present to translate the information orally. In addition, the

interpreter must complete this portion of the Informed Consent for Voluntary Sterilization form.

Name of Member:

Enter the name of the member signing this form.

Language:

Enter the name of the language used in interpreting the Consent to Sterilization form.

Signature of Interpreter:

The interpreter must sign this statement.

Date:

Enter the date the interpreter signs the statement.

STATEMENT OF PERSON OBTAINING CONSENT

Name of Member:

Enter the name of the member who signed the Consent to Sterilization Form.

Sterilization Procedure:

Enter the medical name of the sterilization procedure

Signature of Person Obtaining Consent:

The person who counseled the member and explained to her/him the nature of the sterilization

operation must legibly sign this line. This field cannot be changed or clarified.

Date:

Enter the date that the signature of person obtaining consent was written. This field cannot be

changed or clarified.

Facility:

Enter the name of the facility or provider obtaining the consent.

Address:

Enter the complete address of the facility or provider obtaining the consent.

PHYSICIAN’S STATEMENT

Name of Member:

Enter the name of the member who signed the Consent to Sterilization form.

Date of Operation:

Enter the date that the operation was performed.

Sterilization Procedure:

Enter the medical name of the sterilization procedure.

Select Appropriate Paragraph:

Cross out the paragraph which is not used.

Physician’ s Signature:

Physician must sign the form and enter the date the form is signed. Signature stamps are not

acceptable. This form must be signed and dated after the sterilization is performed to be accepted

as a valid consent for reimbursement for sterilization procedures.