Web2. Name of the sterilization procedure to be performed (e.g., Tubal Ligation or Vasectomy). 3. Beneficiary’s complete birth date (month, day, and year). The beneficiary must be 21 … Webaccurately completed sterilization consent form is received with a claim. For the Medicaid program of Health Care Authority, this is HCA consent form 13-364. Note: Although the agency-approved consent form is HCA 13-364, in some instances providers send the federal consent form, #HHS-687, attached to a claim, which is also acceptable.

Sterilization Consent Form NC Medicaid - NCDHHS

WebBilateral Tubal Ligation Bilateral Tubal Ligation Bilateral Tubal Ligation Bilateral Tubal Ligation Marcus J. Welby M.D. Fields 21 & 22 Cross off the Paragraph which DOES NOT APPLY Fields 27 & 28 Physician Signature & Date must be ON or AFTER Sterilization DATE Fields 2, 6, 13, & 20 Bilateral Tubal Ligation Fields 4, 7, 12, & 18 Penny L. Sillen Webindividual’s signature on this consent form and the date sterilization was performed. (2) This sterilization was preformed less than 30 days but more than 72 hours after the date of the … gsm recharge sans fil

STERILIZATION CONSENT FORM

WebInitials such as “TL” (Tubal Ligation) or “BTL” (Bilateral Tubal Ligation) may be used. 3Recipient’s Date of Birth. Blank field is not acceptable. Acceptable partial dates are: … WebNov 4, 2024 · Tubal ligation seals off the fallopian tubes by either clamping, snipping and sealing, or tying then cutting and sealing them. The fallopian tubes carry a released ovum … WebA Tubal Ligation at our member clinics is completed with a laparoscopic surgery also known as belly button surgery where the incision is made in the belly button. There is minimal … gsm refurbished kpn