• The individual to be sterilized. An informed consent is valid only if at least 30 days, but not more than 180 days, have passed from the date of signature, except in cases of premature delivery or emergency abdominal surgery. If a recipient is sterilized at the time of a premature delivery or emergency abdominal surgery, reimbursement will be made if at least 72 hours have passed since the patient gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been signed at least 30 days before the expected delivery date. An emergency Cesarean birth can be premature delivery, but is not emergency abdominal surgery. 
  
• The interpreter, if one was provided. The interpreter must sign and date the form after the patient signs but before the day of the surgery. 
  
• The person who obtained the consent. The person obtaining consent also must sign and date the form after the patient signs but before the day of the surgery. 
  
• The physician who performed the sterilization procedure. The physician may sign the form shortly before the surgery, the day of surgery or after the surgery. The Minnesota Department of Human Services defines “shortly before” as no more than 15 days prior to the surgery.

Sterilization guidelines have been established by the Minnesota Department of Human Services and must be adhered to for Medica Coice Care and Medica MinnesotaCare members. A copy of the sterilization consent form (DHS-2510-women or DHS-2511-men) must be filed in the member’s medical record. These forms can be obtained by calling:

• DHS Forms Supply: 651-296-9116

* For Medica Choice Care and Medica MinnesotaCare members only.



Return to Regulatory Reporting.