Sterilization is defined as any medical procedure, treatment or operation for the purpose of rendering an individual permanently incapable of reproducing. A Member seeking sterilization must voluntarily give informed consent on the Department of Public Welfare's (DPW) Sterilization Consent Form (PDF) (MA31).
The informed consent must meet the following conditions:
- The Member to be sterilized is at least 21 years old and mentally competent. A mentally incompetent individual is a person who has been declared mentally incompetent by a Federal, State or local court of competent jurisdiction unless that person has been declared competent for purposed which include the ability to consent to sterilization.
- The Member knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure.
- The Member was counseled on alternative temporary birth control methods.
- The Member was informed that sterilization is permanent in most cases, but that there is not a 100% guarantee that the procedure will make him/her sterile.
- The Member giving informed consent was permitted to have a witness chosen by that Member present when informed consent was given.
- The Member was informed that their consent can be withdrawn at any time and there will be no loss of health services or benefits.
- The elements of informed consent, as set forth on the consent form, were explained orally to the Member.
- The Member was offered language interpreter services, if necessary, or other interpreter services if the Member is blind, deaf or otherwise disabled.
- The Member must give informed consent not less than thirty (30) full calendar days (or not less than 72 hours in the case of emergency abdominal surgery) but not more than 180 calendar days before the date of the sterilization. In the case of premature delivery, informed consent must have been given at least 30 days before the expected date of delivery. A new consent form is required if 180 days have passed before the sterilization procedure is provided.
DPW's Sterilization Consent Form (PDF) must accompany all claims for reimbursement for sterilization services. The form must be completed correctly in accordance with the instructions. The claim and consent forms will be retained by AmeriHealth Caritas Pennsylvania.
Submit claims and forms to:
AmeriHealth Caritas Pennsylvania
P.O. Box 7118
London, KY 40742