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Sterilization Consent Form

LDSS-3134 (2/01) PATIENT NAME CHART NO. RECIPIENT ID NO. Sterilization Consent FORM HOSPITAL/CLINIC NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. Consent TO Sterilization I have asked for and received information about Sterilization from _____. When I asked for the (doctor or clinic) information, I was told that the decision to be sterilized is completely up to me.

DISTRIBUTION: 1 – Medical Record File 2 – Hospital Claim 3- Surgeon Claim 4 – Anesthesiologist Claim 5 – Patient . Title: Sterilization Consent Form Author: New York State Department of Health - Office of Health Insurance Programs Subject: LDSS Keywords: Sterilization, Consent, Form

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