Information On Getting Tubes Tied
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Information On Getting Tubes Tied

5.4.1 193 sterilconsentpkt women 2 2010
Women(Your Sterilization Operation)in the withdrawal or withholding of any benefits provided by
You will find the consent form at the back of this booklet.-FP-78-10 (Form 193 Rev.2-10-2010)
Alabama Medicaid Agency

(Revised 8-30-02Is Important To You
Sterilization (tying your tubes) is anfor you to become pregnant.

This booklet tellsyou have your tubes tied.

You should read allof this paper.
Both men and women can be sterilized.

IfIf Medicaid Is To Pay For YourSterilization, Certain Rules Must Be Met: -

You must be at least 21 years old.-

You must wait at least 30 days to have the
operation after you sign the consent
(permission) form.

The only exception to
this is when you have a premature birth or
emergency abdominal surgery at least 72
hours after you sign the form.-

Your consent to sterilization cannot be
given while you are in labor or childbirth
or under the influence of alcohol or other
substances that affect your ability to think
clearly.-

You may, if you choose, bring someone
with you when you sign the consent form.-

Your consent is good for 180 days (6
months) from the date you sign the form.Making Up Your Mind
Being sterilized is completely up to you.No one can force you to be sterilized.

If you
Make sure you do not want to havechildren ever again, for any reason, before
If you have decided not to becomea safe, effective operation.

It requires ato your uterus.

Blocking the tubes makespregnancy impossible.

(See figure below.)
Your monthly bleeding (period) continuesas before.

This operation will not causeWhat are the types of operations I can
There are four types of tubal ligation:Laparoscopy, Laparotomy, Mini-Laparotomyand Vaginal Method.

(See chart on next

The operation you have depends on yourhealth and your doctor.

Talk to him or her
There are discomforts, risks and benefitstied.

Talk with your doctor or clinic.
Tying your tubes should be consideredpermanent and
This operation works almost all the time,1,000 will get pregnant.

This is usually be-back together.
Having your tubes tied is more than 99%effective.

(This is higher than all other ways ofpreventing pregnancy.)Types of
How Operation
The Time
Hospital
RecoveryTubal Ligation

Is Done
It Takes
Stay

TimeStomach is inflated with a harmless gasAbout 30Less than2 - 3 days.theminutes24 hours.Usually cannavel.

Sometimes another tiny openinghave sexis made in lower stomach.

1 to 2 stitcheswithin a feware needed.
days.LaparotomyDoctor makes a 3 - 5" opening in lowerAbout 30A few2 weeks.ROT-OH-MEE)by cutting,minutesclamping, or cauterizing.

The openingwithin a fewis stitched closed.days
information on getting tubes tied
.Doctor makes a 1 - 2" opening in lowerAbout 30Less than2 - 3 days.stomach and seals tubes by cutting,minutes.24 hours.Usually canclamping, or cauterizing.

The openinghave sexis stitched closed.within aVaginal MethodDoctor makes a small opening in backAbout 30Less than2 - 3 days.of vagina.

After the tubes are sealed, theminutes.24 hours.Cannot haveopening is closed with special stitchessex untilthat do not have to be removed.vagina heals -

usually 3 - 4

weeks.
If you are not ready to have your tubespregnancy available to you.

They are the pill,
Talk to your doctor or clinic if you want
You can have your tubes tied at any time inyour life.

For Medicaid to pay for the opera-
You can have your tubes tied even if you

You can have the operation after having ababy, even if you have a baby by CesareanSection.

In either of these two cases, you
Your consent must be given at least 30 daysbefore you have your tubes tied.

Your consent
All of your questions should be answered
If you decide you dont want to have your
If you are sure you do not want to bearBe Sure To Take ThisPaper and Your SignedConsent Form With You.STERILIZATION CONSENT FORMNOTICE:

YOUR DECISION AT ANY TIME TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITScontrol are available which are temporary.

I explained that sterilization is differentleast 21 years old and appears mentally competent.

He/She knowingly andcontrol are available which are temporary.

I explained that sterilization is differentleast 21 years old and appears mentally competent.

He/She knowingly andindividuals signature on the consent form.

In those cases, the second paragraph(1)At least thirty days have passed between the date of the individuals(2)This sterilization was performed less than 30 days but more than 72 hours(1)____(2)____CONSENT TO STERILIZATIONis completely up to me.

I was told that I could decide not to be sterilized.

If Itreatment.

I will not lose any help or benefits from programs receiving Federalpermanent and notfuture.

I have rejected these alternatives and chosen to be sterilized.explained to me.

All my questions have been answered to my satisfaction.sign this form.

I understand that I can change my mind at any time and that myI am at least 21 years of age and was born on (, to:

Representative of the Department of Health and Human Services ordetermining if Federal laws were observed.

I have received a copy of this form.(please check)American Indian or

_____Black (not ofAlaska NativeHispanic origin)Hispanic
_____White (not ofsterilized by the person obtaining the consent.

I have also read him/her theexplained its contents to him/her.

To the best of my knowledge and belief he/sheCopy 1 Copy 2 HPCopy 3 Patients Permanent Record.
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