Ct Dss Consent for Sterilization W 612 Form
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People also ask
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What consent is required for sterilization?
STATEMENT OF PERSON OBTAINING CONSENT To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure.
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What states require spousal consent for sterilization?
Statutes in Georgia, North Carolina, and Virginia requie the written consent of the patient's spouse to voluntary sterilizations. In the absence of such a statute, no definitive answer can be given. Every individual does have the right to consent to any lawful Medical treatment or procedure.
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What are the requirements for a woman to be sterilized?
All women can have female sterilization. No medical conditions prevent a woman from using female sterilization. This checklist asks the client about known medical conditions that may limit when, where, or how the female sterilization procedure should be performed.
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What is the consent for sterilization form in SC?
The Consent for Sterilization - SCDHHS form 687, is required for ALL procedures intended to result in sterilization. The Consent for Sterilization - SCDHHS form 687, is NOT required when a Hysterectomy is to be performed and prior sterilization has occurred.
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What is a PM330 consent form?
CONSENT FORM PM 330 State of California -- Health and Human Services Agency NOTICE Department of Health Services YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
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Does CT Medicaid accept paper claims?
A: All claims must be submitted electronically. The instructions for claims can be found at .ctdssmap.com in the Internet Claims Submission FAQ found here. Please see information regarding exceptions above.
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Where do I mail my Medicaid claims in CT?
Please call CHNCT Provider Relations at (800) 440-5071 to enroll and for billing instructions. Submit claims for all other eligibility categories to EDS, P.O. Box 2941, Hartford, Ct. 06104. Submit your claim on a CMS 1500 form.
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