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Sterilization forms from Utah Medicaid:

  • Hysterectomy Acknowledgment Form
  • 499-A Consent for Sterilization Form

Sterilization form from Molina Healthcare:

  • FAX cover sheet for Sterilization or Hysterectomy

Q&A’s:

Why is Molina Healthcare asking for these forms?

Molina follows all State Medicaid guidelines. In the State Provider manual,
per Title 42 Code of Federal Regulations, all sterilizations require a valid
consent form. All required fields must be completed for timely processing.

Please use the most current forms found on the Utah Medicaid Formswebsite: http://health.utah.gov/medicaid/provhtml/forms.htm/forms.htm

Select appropriate form from the Forms drop down box:

  • Hysterectomy Acknowledgment Form
  • SterilizationConsent

Does Molina Healthcare require Providers to submit the fax cover sheetwith the required forms?

Yes, Molina Healthcare requires providers to submit the FAXcover sheet with the appropriate form in order to identify theclaim connected to the consent form to be processed forpayment.

Where do I send the FAX cover sheet and attached Sterilzation forms forprocessing?

Please fax the FAX cover sheet and a copy of the 499-A Consent forSterilzation form/or the Hysterectomy Acknowledgment form with anysupporting documentation to:

FAX # 877-682-2218
Attn: ProviderDisputes

 New FAX cover sheet


 

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