September 25, 2015

State of Alabama
Press Release: Medicaid

Changes to the Plan First Program Sterilization Consent Form Completion and Submission Process

   PDF Version
 

TO:     All Plan First/Family Planning Providers (physicians, FQHCs, IRHCs, PBRHCs), Hospitals, Obstetricians-Gynecologists and Urologists
  

Attention:  All Plan First/Family Planning Providers (physicians, FQHCs, IRHCs, PBRHCs), Hospitals, Obstetricians-Gynecologists and Urologists.

 

The Sterilization Consent Form (Form 193) is now available on the Alabama Medicaid Agency’s website in an electronic fillable format. The electronic fillable version can be accessed at this link. The form must be printed to complete signatures and dates. 

 

Hewlett-Packard Enterprise Services (HPES) will now accept faxed copies of the electronic fillable version of the Sterilization Consent Form at the following fax number: (334) 215-4275.  Mark it to the attention of Medical Policy Unit/Consent Forms on the fax cover sheet. The following guidelines apply:
   

o   Only electronic fillable Sterilization Consent Forms with signatures and dates completed in BLACK ink will be accepted via fax by HPES.

o   Handwritten Sterilization Consent Forms will not be accepted via fax.
   

A completed copy of the Sterilization Consent Form (electronic fillable format or handwritten format) can also be mailed to HPES, P.O. Box 244032, Montgomery, AL 36124-4032, attention Medical Policy Unit/Consent Forms.

 

Medicaid will no longer print large quantities of Sterilization Consent Forms for provider disbursement but will maintain limited quantities for emergency situations.

 

Additional information and guidance regarding the Sterilization Consent Form submission process can be found on Medicaid’s website at this link, Provider Manual, Appendix C, Family Planning.

In addition, a detailed Instruction Guide is available on Medicaid’s website at this link.

 

For questions regarding the Sterilization Consent Form process, contact Ruth Harris, Program Manager, Plan First/Family Planning Program at 334-353-3562 or via e-mail at ruth.harris@medicaid.alabama.gov.

 

 



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