The acknowledgement statement for hysterectomies must be signed by the patient or a representative and the sterilization consent form must be signed by the patient. For beneficiaries with physical disabilities, these required statements must be signed by the patient. If the patient signs 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. This procedure is to be used for patients who are not mentally impaired.

For hysterectomies for individuals with intellectual disabilities, the acknowledgement of sterility statement is required. A guardian must petition the court for permission to sign for the patient giving consent for the procedure to be performed. A copy of the court petition and the acknowledgement statement must be attached to the claim. Sterilization procedures for birth control purposes are not covered for the mentally incompetent.