CurrentUnitedHealthcarePolicy N/A

Hysterectomy and Sterilization Consent/Receipt Forms (FD-189 / Consent Form 7473-M ED)

This document provides federally prescribed forms, instructions, and Medicaid billing requirements for hysterectomy (FD-189) and sterilization consent (Consent Form 7473-M ED) procedures, and governs providers submitting claims for these procedures to Medicaid.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy and Sterilization Consent/Receipt Forms (FD-189 / Consent Form 7473-M ED)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttach a properly completed FD-189 or Sterilization Consent Form to any claim for hysterectomy or sterilization and submit as hard copy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

FD-189 (Rev 7/83)Hysterectomy form version

7473-M ED (3/81)Sterilization consent form

30-180 daysConsent timing window

Hard copyBilling method

Documentation & Timing Requirements

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Mandatory documentation and timing criteria

Documentation and timing criteria required for submission of hysterectomy and sterilization claims to Medicaid.

A properly completed Hysterectomy Receipt of Information Form (FD-189) must be attached to any claim (hospital, operating physician, anesthesiologist, clinic, etc.) involving hysterectomy procedures when submitted for payment.

Hysterectomy claims must be submitted as hard copy; electronic billing is not permitted.

Photocopies of the FD-189 are acceptable; providers may obtain additional copies from the Fiscal Agent.

A properly completed Sterilization Consent Form (replica of the Federal form, Consent Form - 7473 M ED) must be attached to any claim (hospital, operating physician, anesthesiologist, clinic, etc.) involving sterilization procedures when submitted for payment.

Sterilization claims must be submitted as hard copy; electronic billing is not permitted.

Photocopies of the Sterilization Consent Form are acceptable; providers may obtain additional copies from the Fiscal Agent.

Sterilization consent timing

Recipient must personally sign and hand-date the Sterilization Consent Form at least 30 days and not more than 180 days prior to the sterilization procedure.
Exceptions
- Sterilization performed less than 30 days but more than 72 hours after signature is permissible only for premature delivery (the expected date of delivery must be stated).
- Sterilization performed less than 30 days but more than 72 hours after signature is permissible only for emergency abdominal surgery (the emergency must be described).

Signatures and timing for person obtaining consent and physician

The person obtaining consent must sign and date Section IV at least 30 days, but not more than 180 days prior to the sterilization procedure.
The physician must indicate in the form which paragraph applies concerning the 30‑day waiting period and must sign and date the form after the surgery has been performed for sterilization; physician signature requirements for the FD-189 must follow the form's instructions.

Forms include consent to release the form and related records to the Department of Health and Human Services or authorized employees for purposes of determining compliance with Federal laws.

Race and ethnicity designation is requested on the Consent Form but is optional.

What Providers Must Do

Documentation Required

Attach completed FD-189 and submit hard copy

Attach a properly completed Hysterectomy Receipt of Information Form (FD-189) to any claim (hospital, operating physician, anesthesiologist, clinic, etc.) involving hysterectomy procedures; such claims must be submitted as hard copy (electronic billing is not permitted).

Documentation Required

Attach completed Sterilization Consent Form and submit hard copy

Attach a properly completed Sterilization Consent Form (replica of the Federal form, Consent Form 7473-M ED) to any claim (hospital, operating physician, anesthesiologist, clinic, etc.) involving sterilization procedures; such claims must be submitted as hard copy (electronic billing is not permitted).

Documentation Required

Photocopies acceptable; extra copies from Fiscal Agent

Photocopies of the FD-189 and the Sterilization Consent Form are acceptable for submission. Providers may obtain additional copies of either form from the Fiscal Agent; however, claims requiring these forms remain hard copy restricted.

Forms Defined

Hysterectomy Receipt of Information Form (FD-189)

Form name and identifierHysterectomy Receipt of Information Form (FD-189, Rev 7/83)

PurposeDocuments that the recipient received oral and written information about hysterectomy, had questions answered, and consented; used for Medicaid claim submission.

Key contentStatement that hysterectomy prevents future pregnancy; acknowledgement of information received, persons consulted, consent to the procedure and related treatments, and consent to release form and related medical records to HHS for compliance review.

Signature requirementRecipient must sign and date the FD-189 (Recipient's Signature; Date: Month/Day/Year).

Billing requirementA properly completed FD-189 must be attached to any claim involving hysterectomy procedures; claims must be submitted as hard copy.

Sterilization Consent Form (7473-M ED)

Form name and identifierSterilization Consent Form (Consent Form - 7473-M ED)

PurposeFederally prescribed consent form documenting informed consent for sterilization and that the decision will not affect federally funded benefits.

Timing requirementSignature must be at least 30 days before the procedure; consent expires 180 days from the date of signature (30–180 days window).

Age requirement and statementAffirms the recipient is at least 21 years of age and includes birth date entry and recipient's statement of voluntary consent.

Content and rights noticeExplains permanence of sterilization, alternatives offered, right to change mind, and that refusal will not result in withholding of benefits or services from federally funded programs.