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.
Sterilization Process and FAQ for Providers Molina Healthcare of Utah/Medicaid/CHIP 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 Forms website: http://health.utah.gov/medicaid/provhtml/forms.htm Select appropriate form from the Forms drop down box: HysterectomyAcknowledgment Form SterilizationConsent New FAX cover sheet Does Molina Healthcare require Providers to submit the fax cover sheet withtherequired forms? Yes, Molina Healthcare requires providers to submit the FAX cover sheet with the appropriate form in order to identify the claim connected to the consent form to be processed for payment. WheredoI sendtheFAXcoversheetandattachedSterilzationforms for processing? Please fax the FAXcover sheet andacopy of the 499-A Consentfor Sterilzation form/or the Hysterectomy Acknowledgmentform with any supportingdocumentation to: FAX# 877-682-2218 Attn:Provider Disputes Provider DisputesAdobe PDF Library 15.0