Use this SOP to protect member rights and complete the informed-consent process for human sterilization. Besa Health team members must ensure that consent is voluntary, informed, properly documented, and obtained on the current DHCS 8649 form before a sterilization procedure is performed.
📚 Resources Needed
Written Member Rights information available at the office site
DHCS Medi-Cal Helpline and Telephone Service Center: (800) 541-5555
Provider NPI number when ordering DHCS 8649 forms by telephone
Besa Health staff-training record and the member’s medical record
✅ Before You Start
Confirm that the current DHCS 8649 form and the appropriate DHCS sterilization booklet are available. DHCS 8649 is the only sterilization consent form accepted by DHCS for Medi-Cal and Family PACT sterilization services.
The informed-consent discussion must be conducted by the physician or the physician’s designee. Staff may support the process only within their assigned role.
Provide information in a language and format the member can understand. Arrange an interpreter or other effective communication assistance when needed and document the assistance provided.
Consent must be voluntary and free from fraud, pressure, duress, or undue influence. The member may withhold or withdraw consent at any time before sterilization without losing future care, treatment, or federally funded benefits.
Do not obtain sterilization consent while the member is in labor or childbirth, seeking or obtaining an abortion, or under the influence of alcohol or another substance that affects awareness.
🚀 Tips & Tricks
Use the current DHCS 8649 form and follow its instructions exactly. Incomplete, inconsistent, altered, or incorrectly timed forms may be rejected and may delay reimbursement.
Give the member time to ask questions and make a decision. Use teach-back to confirm understanding without pressuring the member toward or away from sterilization.
Keep the member’s name and procedure name consistent throughout DHCS 8649 and consistent with the medical record and claim.
Have the provider’s NPI number ready before calling (800) 541-5555 to order the form.
📘 Instructions
Step 1: Maintain And Explain Written Member Rights
Keep written Member Rights information available at the office site in a location staff can identify and access.
Staff must be able to locate the written Member Rights list and explain how the member can use the information.
Member-rights information includes the right to informed consent and the specific protections that apply to human sterilization consent.
Step 2: Train Staff And Document Education
Train or provide information to site personnel about member rights, informed consent, and human sterilization consent.
Staff education may be provided through informal or formal in-services, new-staff orientation, or external training courses.
Document completed staff education according to the Besa Health training-record process, including the topic, date, delivery method, and participants.
Step 3: Provide General Informed-Consent Information
Before any proposed treatment or procedure that includes medically significant risks, inform the member about the proposed treatment or procedure and its purpose.
Explain the medically significant risks, the available alternate courses of treatment, the option of no treatment, and the risks involved in each alternative and in non-treatment.
Tell the member the name of the person who will carry out the treatment or procedure. If the physician performing the sterilization changes, notify the member of the new physician’s name and the reason for the substitution before preanesthetic medication is administered.
Answer the member’s questions and confirm that the information was understood. Document the discussion and place the signed consent in the member’s medical record.
Step 4: Conduct The Sterilization Consent Discussion
The physician or physician’s designee must conduct the informed-consent process and offer to answer every question the member may have.
Give the member a copy of the current DHCS 8649 consent form and the applicable DHCS booklet before consent is obtained. The member must receive the booklet and a copy of the consent form.
Advise the member that consent may be withheld or withdrawn at any time before sterilization without affecting the right to future care or treatment and without loss or withdrawal of federally funded benefits.
Fully describe available alternatives for family planning and birth control, including temporary methods that would allow the member to retain the ability to become pregnant, bear children, or father children.
Explain that sterilization is intended to be permanent and must be considered irreversible.
Thoroughly explain the specific sterilization procedure to be performed, including the nature and purpose of the procedure.
Fully explain the discomforts and risks that may accompany or follow the procedure, including the type and possible effects of anesthesia, and fully explain the expected benefits or advantages.
Explain the approximate hospital stay, recovery time, financial cost to the member, whether the procedure is established or new, and the applicable waiting period when required by the current DHCS instructions.
Step 5: Confirm Eligibility, Capacity, And Timing
For Medi-Cal-covered sterilization, confirm that the individual is at least 21 years old when written consent is obtained, appears mentally competent, can understand the nature and consequences of the procedure, is not institutionalized as defined by the applicable rules, and is consenting voluntarily.
At least 30 days and no more than 180 days generally must pass between the date of written informed consent and the sterilization procedure.
The limited premature-delivery and emergency-abdominal-surgery exceptions require at least 72 hours after written consent and all conditions and certifications required by the current DHCS 8649 instructions. Do not treat an elective abortion as emergency abdominal surgery.
Do not proceed if the consent timing, member eligibility, voluntariness, comprehension, or required documentation cannot be confirmed. Contact DHCS or the responsible clinician for guidance.
Step 6: Complete DHCS 8649
Use the current DHCS 8649 Consent for Sterilization form and complete every applicable field according to the form and DHCS instructions.
Ensure the member’s name, birth date, procedure name, physician or clinic, facility information, and all required dates are accurate and consistent throughout the form and with the medical record and claim.
Obtain every signature and date required on DHCS 8649: the individual to be sterilized; the interpreter, when one was used; the person who obtained consent; and the physician who performed the procedure.
If the member signs with an X, another symbol or character, or a non-Latin alphabet, follow the current DHCS instructions for a witness countersignature.
Do not pre-sign, backdate, alter, or complete a required certification without the signer’s direct review and authorization.
Step 7: Give Copies And Document The Medical Record
Give the member the DHCS sterilization booklet and a copy of the completed consent form as required.
Document the informed-consent discussion, questions and answers, alternatives discussed, the member’s understanding and voluntary decision, communication assistance, booklet and form copies provided, and any withdrawal or refusal.
Place the signed DHCS 8649 in the member’s medical record. Retain and submit copies as required by DHCS billing and recordkeeping instructions.
A signed form does not replace the informed-consent conversation. The documentation must show that the required information was discussed and understood.
Step 8: Order Or Replace Forms
Download the current DHCS 8649 and sterilization education materials from the DHCS Sterilization Consent Form and Education Materials page whenever possible.
To order forms or obtain Medi-Cal assistance, call the DHCS Medi-Cal Helpline and Telephone Service Center at (800) 541-5555, Monday through Friday, 8:00 a.m. to 5:00 p.m.
Providers must have their NPI number available when ordering DHCS 8649 by telephone.
🛠 Troubleshooting
The Member Has Questions Or Is Unsure
Pause the consent process. The physician or physician’s designee must answer the questions, review alternatives and risks, and allow additional decision time. Do not obtain a signature until the member demonstrates understanding and chooses voluntarily.
The Member Withdraws Or Withholds Consent
Stop the sterilization plan and notify the responsible clinician. Do not pressure the member, and do not reduce or withdraw future care, treatment, or federally funded benefits because of the decision. Document the withdrawal or refusal.
The Form, Booklet, Or Language Version Is Unavailable
Do not substitute an unapproved form or omit the booklet. Use the DHCS Sterilization Consent Form and Education Materials page, call (800) 541-5555 with the provider NPI number, and arrange the appropriate translated material or interpreter.
The Consent Date Is Outside The Allowed Window
Do not proceed based on an expired or prematurely effective consent. Obtain clinical and compliance guidance and complete a new valid consent process when required. Apply only the documented premature-delivery or emergency-abdominal-surgery exception when every condition is satisfied.
Information Is Inconsistent Or Missing
Stop and correct the form before the procedure. Confirm that names, dates, procedure descriptions, signatures, and certifications match throughout DHCS 8649, the medical record, and the claim. Never backdate or alter a signature.
✅ Completion Check
Written Member Rights are available, and staff can locate and explain them.
Staff training covers informed consent and human sterilization consent and is documented through an in-service, orientation, or external training record.
The physician or physician’s designee conducted the consent discussion and answered the member’s questions.
The member received the current DHCS 8649 form and the applicable DHCS sterilization booklet.
Alternatives, non-treatment, irreversibility, the specific procedure, the person performing it, discomforts, risks, anesthesia effects, benefits, and the right to withdraw were explained.
Eligibility, capacity, voluntariness, communication needs, and the applicable 30-to-180-day timing requirements were confirmed.
All required DHCS 8649 fields, signatures, certifications, and dates are accurate and complete.
The member received a copy, and the signed consent and discussion documentation are in the medical record.
References
Forms And Materials: DHCS Sterilization Consent Form and Education Materials • DHCS 8649 Consent for Sterilization • DHCS 8649 Spanish • All About Tubal Sterilization • All About Vasectomy
Rules: 42 CFR § 441.253 • 42 CFR § 441.257 • 42 CFR § 441.258 • California Code of Regulations, Title 22, § 70707 • Medicare Conditions of Participation • Joint Commission member-rights requirements
Source: CalOptima Provider FSR/MRR Binder, page 111 • Updated Oct 24, 2025
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