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016.06.20-216.410. Informed Consent to Sterilization

AR ADC 016.06.20-216.410Arkansas Administrative Code

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 06. Division of Medical Services
Rule 20. Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD) Provider Manual (Refs & Annos)
Section 210.000. Program Coverage -- Hospital and Critical Access Hospital.
Ark. Admin. Code 016.06.20-216.410
016.06.20-216.410. Informed Consent to Sterilization
Currentness
A. By signing the Sterilization Consent Form DMS-615, the patient certifies that she or he understands the entire process.
1. By signing the consent form, the person obtaining consent and the physician certify that, to the best of their knowledge, the patient is mentally competent to give informed consent.
2. If any questions concerning this requirement exist, you should contact the Arkansas Medicaid Program for clarification before the sterilization procedure is performed.
B. The person obtaining the consent for sterilization must sign and date the form after the recipient and interpreter sign, if an interpreter is used.
1. This may be done immediately after the recipient and interpreter sign or it may be done later, but it must always be done before the sterilization procedure.
2. The signature will attest to the fact that all elements of informed consent were given and understood and that consent was voluntarily given.
C. By signing the physician's statement on the consent form, the physician is certifying that shortly before the sterilization was performed, he or she again counseled the patient regarding the sterilization procedure.
1. The State defines “shortly before” as one week (seven days) or less before the performance of the sterilization procedure.
2. The physician's signature on the consent form must be an original signature and not a rubber stamp.
D. Informed consent may not be obtained while the person to be sterilized is:
1. In labor or childbirth,
2. Seeking to obtain or obtaining an abortion or
3. Under the influence of alcohol or other substances that affect the individual's state of awareness.
E. The sterilization must be performed at least 30 days, but not more than 180 days, after the date of informed consent. The following exceptions to the 30-day waiting period must be properly documented on the form DMS-615. View or print Sterilization Consent Form DMS-615 and Checklist.
1. In the case of premature delivery, provided that at least 72 hours have passed between giving the informed consent and performance of the sterilization procedure and that counseling and informed consent were given at least 30 days before the expected date of delivery.
2. In the case of emergency abdominal surgery, provided that at least 72 hours have passed between giving informed consent and the performance of the sterilization procedure.
F. The person is informed, before any sterilization discussion or counseling, that no benefits or rights will be lost because of refusal to be sterilized and that sterilization is an entirely voluntary matter. This should be explained again just before the sterilization procedure takes place.
G. If the person is an individual with a physical disability and signs the consent form with an “X,” two witnesses must also sign and include a statement regarding the reason the patient signed with an “X,” such as stroke, paralysis, legally blind, etc. If a consent form is received that does not have the statement attached, the claim will be denied.
H. A copy of the properly completed form DMS-615, with all items legible, must be attached to each claim submitted from each provider. Providers include hospitals, physicians, anesthesiologists and assistant surgeons. It is the responsibility of the physician performing the sterilization procedure to distribute correct legible copies of the signed Sterilization Consent Form DMS-615 to the hospital, anesthesiologist and assistant surgeon.
I. Sterilizations are covered only when informed consent is properly documented by means of the form DMS-615.
1. View or print a Checklist for Form DMS-615, which lists consent form items that DMS medical staff reviews to determine whether a sterilization procedure will be covered.
2. Using the checklist will help ensure the submittal of a correct form DMS-615.
J. The individual undergoing the procedure must receive, from the physician performing the procedure or the facility in which the sterilization procedure takes place, an identical copy of the completed consent form that he or she signed and dated.

Credits

Eff. Oct. 13, 2003. Amended July 15, 2012.
<Editor’s Note: Nonfunctioning links so in original.>
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.06.20-216.410, AR ADC 016.06.20-216.410
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