When obtaining informed consent for sterilization services for Medi-Cal and Family PACT, providers must use the Consent for Sterilization (DHCS 8649) form. This is the only sterilization consent form accepted by DHCS. The form must be completed in accordance with instructions outlined in the Sterilization (Ster) section found in Part 2 of the Medi-Cal Provider Manual.

Per the California Code of Regulations (22 CCR § 51305.3 Informed Consent Process for Sterilization), individuals must be provided a copy of the consent form and the booklet on sterilization published by the Department.

Question 1: Can we shorten patient names on the form, provided they are consistent throughout the form?
Answer 1: The patient’s name must be consistent throughout the Consent for Sterilization (DHCS 8649) and must match the patient’s name on the claim.

Question 2: In the interpreter section, is that required for services delivered remotely?
Answer 2: The interpreter signature is required as stated in the instructions.

If you have other questions about sterilization services not addressed here, please contact the Department of Health Care Services, Office of Family Planning at FamilyPact@dhcs.ca.gov