Paper Claims and Patient Consent Forms Required for Hysterectomy and Sterilization Procedures for Medicaid Patients


Date Issued: 4/3/2017

Federal regulations require patients to consent to hysterectomy and sterilization procedures. The patient or their proxy must sign the required consent form for the procedure to be considered a covered service under the Medicaid plan.

For these procedures:

  • Submit paper claims AND
  • Include the patient’s completed and signed consent form.

If you submit an electronic claim for these procedures, it will be put on hold (pended) until you resubmit a paper claim with a completed patient consent form.

If EmblemHealth receives a paper claim without the required form, the claim will be returned. We will process the claim only when we get the patient consent form with the paper claim.

For hysterectomy procedures, use the Acknowledgment of Receipt of Hysterectomy Information Form (LDSS-3113).

For procedures performed for sterilization (Code F), use the Sterilization Consent Form (LDSS-3134).

You may obtain both forms from the New York State Department of Health’s website at Local Districts Social Service Forms.