CurrentUnitedHealthcarePolicy N/A

Hysterectomy and Sterilization Consent and FD-189/Consent Forms

This document provides required federally prescribed Medicaid forms (FD-189 Hysterectomy Receipt of Information and the sterilization Consent Form) and detailed instructions for completing them; it governs providers submitting claims for hysterectomy or sterilization procedures and the documentation that must accompany claims.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy and Sterilization Consent and FD-189/Consent Forms

Policy CodePolicy N/A

Change TypeMinor update / no material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttach a properly completed FD-189 to any hysterectomy claim and the federally-prescribed Consent Form to any sterilization claim; both must be submitted as hard copy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

FD-189Hysterectomy form identifier

7473-MSterilization consent form

hard copy restrictedBilling restriction

30–180dConsent timing window

acceptablePhotocopies

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Documentation & Timing Requirements

Documentation and timing criteria for hysterectomy and sterilization claims

Documentation and timing requirements that must be met and attached to claims for payment:

Any hysterectomy claim (hospital, operating physician, anesthesiologist, clinic, etc.) must have a properly completed Hysterectomy Receipt of Information Form (FD-189) attached when submitted for payment; hysterectomy claims are hard copy restricted (electronic billing is not permitted).

Any sterilization claim (hospital, operating physician, anesthesiologist, clinic, etc.) must have a properly completed federally‑prescribed Sterilization Consent Form (Consent Form - 7473 M ED) attached when submitted for payment; sterilization claims are hard copy restricted (electronic billing is not permitted).

Photocopies of the FD-189 and the Sterilization Consent Form are acceptable; additional copies may be obtained from the Fiscal Agent.

Recipient signature requirements: the recipient must personally sign and hand‑date the FD-189 and the Sterilization Consent Form as specified on the forms, confirming voluntary informed consent.

Sterilization consent timing: the recipient must personally sign and date the Sterilization Consent Form at least 30 days and not more than 180 days prior to the sterilization procedure (consent expires 180 days from the date of signature).

Exceptions to 30‑day waiting period

If sterilization is performed less than 30 days but more than 72 hours after signature, the physician must document that the delivery was premature and state the expected date of delivery, or that an emergency abdominal surgery occurred and describe the emergency (physician must indicate the applicable paragraph on the form).

Form completion and signatory requirements: the person obtaining consent must complete Section IV items (including their signature and date) at least 30 days but not more than 180 days prior to the sterilization procedure; the physician must sign and date the form after the surgery is performed and indicate the applicable paragraph regarding timing.

Age requirement for sterilization consent: the individual must be at least 21 years of age to consent to sterilization as stated on the Consent Form.

Required Forms and Consent Timing

Forms required for procedure claimsmixed

FD-189	Hysterectomy Receipt of Information Form (must be properly completed and attached to any hysterectomy claim; hard copy restricted; photocopies acceptable)
7473-M ED	Consent Form (federally prescribed sterilization consent form; must be properly completed and attached to any sterilization claim; hard copy restricted; photocopies acceptable)
Consent Form	Federally-prescribed sterilization Consent Form (replica of federal regulation form; providers must use when submitting sterilization claims)

Sterilization consent timing window

Required timing windowConsent must be personally signed and hand-dated at least 30 days and not more than 180 days prior to the sterilization procedure.

Exception — premature delivery or emergency abdominal surgeryIf sterilization is performed less than 30 days but more than 72 hours after signature, the physician must document premature delivery (state expected date) or emergency abdominal surgery (describe emergency) and indicate the applicable paragraph on the form.

Minimum interval enforced on form sectionsSection I and Section IV require dates/signatures that reflect the 30–180 day rule for both recipient and person obtaining consent (must be completed at least 30 days but not more than 180 days prior to procedure).

Consent expirationThe recipient's consent expires 180 days from the date of signature on the Consent Form.

What Providers Must Attach and Do

Prior Authorization

Attach completed FD-189 to all hysterectomy claims

Attach a properly completed Hysterectomy Receipt of Information Form (FD-189) to any hysterectomy claim (hospital, operating physician, anesthesiologist, clinic, etc.). Hysterectomy claims must be submitted as hard copy; electronic billing is not permitted. Photocopies of the FD-189 are acceptable and additional copies may be obtained from the Fiscal Agent.

FD-189 must be properly completed and attached to the claim.
Hysterectomy claims are hard copy restricted — electronic billing is not permitted.
Photocopies of the FD-189 are acceptable; additional copies available from the Fiscal Agent.

Prior Authorization

Attach federally-prescribed Sterilization Consent Form to all sterilization claims

Attach a properly completed federally-prescribed Sterilization Consent Form (Consent Form - 7473 M ED) to any sterilization claim (hospital, operating physician, anesthesiologist, clinic, etc.). Sterilization claims must be submitted as hard copy; electronic billing is not permitted. Photocopies of the Consent Form are acceptable and additional copies may be obtained from the Fiscal Agent.

Form Definitions

FD-189 (Hysterectomy Receipt of Information Form)

Form identifierHysterectomy Receipt of Information Form (FD-189).

PurposeDocuments that the recipient was informed orally and in writing that hysterectomy removes the uterus, eliminates future pregnancy and menstrual periods, and confirms discussion with staff and opportunity to ask questions.

What it documentsRecipient's acknowledgement of information, consent to hysterectomy and related necessary treatments, and consent to release this form and medical records to federal representatives for compliance review.

Signature requirementRecipient's signature and date are required on the FD-189.

Form revision infoFD-189 (Rev 7/83).

Sterilization Consent Form