Form LDSS-3134 NYS Sterilization Consent: 30-Day Wait and Withdrawal

Form LDSS-3134 is New York State’s Medicaid Sterilization Consent Form, and it must be completed correctly for any sterilization procedure Medicaid will pay for. You can download it from the New York State Department of Health’s forms page or get a copy from your provider’s office; a Spanish version, LDSS-3134s, is available at the same place. The form is filled out in sections by different people at different times: you, the person who counsels you, an interpreter if one is needed, a witness if the procedure is in New York City, and the surgeon on the day of surgery.

Who Can Sign and When

You must be at least 21 years old on the day you sign. You must also be mentally competent, meaning no court has declared you incompetent, or if one did, your competency has since been restored for purposes that include consenting to sterilization.1Cornell Law Institute. 18 NYCRR 505.13 – Family Planning

Federal rules also forbid anyone from asking you to sign while you are:

Consent collected in any of those circumstances is invalid, and Medicaid will not reimburse the procedure.

Filling Out the Form Section by Section

The form is completed during a counseling session with a healthcare professional, not on your own. Each section has its own signer.

Your Section: Consent to Sterilization

Write your full legal name as it appears in your medical records, the name of the doctor who will perform the procedure, the specific operation (for example, “tubal ligation” or “vasectomy”), and the method to be used. By signing, you confirm that you were told about temporary birth control methods, that you understand sterilization is permanent and not reversible, that the procedure will not happen until at least 30 days after you sign, that you can change your mind at any time without losing Medicaid or other federally funded benefits, and that you received a copy of the completed form.3New York State Department of Health. LDSS-3134 Sterilization Consent Form

Fill in the date you sign carefully. That date starts the 30-day waiting period and the 180-day expiration clock, and a transposed month and day is enough to cause a billing denial.

Statement of Person Obtaining Consent

The counselor signs to confirm they explained temporary birth control alternatives, told you sterilization is permanent, and informed you that you can withdraw consent at any time without losing benefits. They also attest that, to the best of their knowledge, you are at least 21 and appear mentally competent.3New York State Department of Health. LDSS-3134 Sterilization Consent Form

Interpreter’s Statement

If you do not understand English or the language on the form, an interpreter must be provided. The interpreter signs a separate statement confirming they translated both the oral counseling and the written form, and that you appeared to understand. Their name and the language used are recorded on the form.3New York State Department of Health. LDSS-3134 Sterilization Consent Form

Physician’s Statement

The surgeon completes this section shortly before performing the procedure, not weeks in advance. The physician confirms the counseling, verifies your age and apparent competence, and certifies that the required waiting period has elapsed.3New York State Department of Health. LDSS-3134 Sterilization Consent Form If one of the emergency exceptions applies, the physician uses a different paragraph on the form to certify the 72-hour minimum and checks a box indicating which exception applied.

NYC Witness Certification

Sterilizations performed in New York City require an extra step. A witness must be present during the counseling session and watch you sign in your own handwriting, then complete a certification section with their name, title, and the date.3New York State Department of Health. LDSS-3134 Sterilization Consent Form If your procedure is scheduled at a facility within the five boroughs, confirm with the provider ahead of time that a witness will be there. A missing witness signature will hold up the claim.

The 30-Day Wait, the 72-Hour Exceptions, and the 180-Day Expiration

The procedure cannot happen until at least 30 days after you sign. If the surgery is performed before the 30 days pass, Medicaid will refuse the claim, and the provider absorbs the cost.4eCFR. 42 CFR 441.253 – Sterilization of a Mentally Competent Individual

Two narrow exceptions shorten the wait to 72 hours:

  • Premature delivery. You may consent at the time of premature delivery, but only if you originally gave informed consent at least 30 days before the expected due date.4eCFR. 42 CFR 441.253 – Sterilization of a Mentally Competent Individual
  • Emergency abdominal surgery. If you need unplanned abdominal surgery and want sterilization performed at the same time, consent must still have been given at least 72 hours earlier. The physician documents the emergency on the form.

Your signed consent expires 180 days after the signature date. If the procedure has not happened by then, you sign a new LDSS-3134 and the 30-day waiting period starts over.3New York State Department of Health. LDSS-3134 Sterilization Consent Form

Your Right to Withdraw

You can change your mind at any point before the surgery. Withdrawing consent does not require paperwork. Telling your provider you no longer want the procedure is enough, and no federally funded benefit, including Medicaid, can be withheld or reduced because you decided not to go through with it.3New York State Department of Health. LDSS-3134 Sterilization Consent Form

Copies and Submission

After the physician completes the final section on the day of surgery, the form goes to the facility’s administrative office for processing through Medicaid billing. LDSS-3134 is distributed as five copies:3New York State Department of Health. LDSS-3134 Sterilization Consent Form

  • Copy 1: Medical record file
  • Copy 2: Hospital claim
  • Copy 3: Surgeon claim
  • Copy 4: Anesthesiologist claim
  • Copy 5: Patient

You are entitled to your own copy, and the form itself includes a line where you confirm you received one. Keep it. If a billing dispute comes up months later, your copy is proof that every step was followed.

Hysterectomies Use a Different Form

LDSS-3134 is not the right form when a hysterectomy is medically necessary rather than performed for sterilization. Medicaid will not cover a hysterectomy done only to prevent future pregnancies. When a hysterectomy is medically justified but will also result in permanent sterility, the provider must obtain both the LDSS-3134 and a separate form, the DSS-3113 Acknowledgment of Hysterectomy, which confirms the patient was told, orally and in writing, that the procedure will make her permanently unable to reproduce.5eMedNY. Inpatient Policy Guidelines The DSS-3113 is waived only if the patient was already sterile or the surgery is a life-threatening emergency; in either case, the surgeon completes an attestation explaining the exception.

Paperwork Errors That Cause Denials

Claims are denied more often for paperwork problems than medical issues. The most avoidable ones:

  • Surgery performed before the 30 days pass. Even one day short rejects the entire claim. Count carefully from the day after the signature date.
  • Surgery performed after 180 days. An expired form means a new consent and a new waiting period.
  • Wrong or abbreviated physician name. The full legal name of the surgeon must appear. Initials, abbreviations, or “doctor on call” are not accepted.
  • White-out or erasures. Corrections with white-out are prohibited. If a mistake is made, ask whether a new form is needed.
  • Illegible copies. Every field on every copy must be readable.
  • Missing signatures or dates. Patient, counselor, interpreter (if used), witness (in NYC), and physician all must sign and date. A single blank field can invalidate the form.

Reviewing the form for completeness before you leave the counseling session is the simplest way to keep the claim from being denied and the procedure from being rescheduled.