The Texas Medicaid sterilization consent form, officially Form F00090, documents your voluntary decision to have a permanent sterilization procedure such as a tubal ligation or vasectomy. To be valid for Medicaid reimbursement, the form must be fully completed with four separate signatures, and at least 30 days (but no more than 180) must pass between the date you sign and the date of surgery. Get any of that wrong and Medicaid will deny the claim.
Who Can Sign the Form
Federal rules set the eligibility bar. You must be at least 21 years old on the day you sign, and you must be mentally competent to understand that the procedure is permanent.1eCFR. 42 CFR 441.253 – Sterilization of a Mentally Competent Individual The decision has to be entirely your own. Pressure from a provider, family member, or institution invalidates the consent.
There are moments when consent cannot be taken at all. A provider may not ask you to sign while you are in labor or childbirth, while you are seeking or undergoing an abortion, or while you are under the influence of alcohol or any substance that affects your awareness.2eCFR. 42 CFR 441.257 – Informed Consent A form signed in any of those situations will not be honored.
Where to Get the Form
Form F00090 is a downloadable PDF on the Texas Medicaid & Healthcare Partnership (TMHP) website.3Texas Medicaid & Healthcare Partnership (TMHP). F00090 – Sterilization Consent Form Most clinics keep copies in the office and will print one at the visit where sterilization first comes up. The Texas form mirrors the federal HHS-687 consent form; if your provider hands you either version, the content and requirements are the same.
What Your Provider Must Explain Before You Sign
Before you sign, the person obtaining your consent has to walk you through specific points and then sign a statement on the form confirming they did so. They must cover:
- That the procedure is intended to be permanent and should be treated as a decision you cannot undo.
- That temporary birth control methods exist and are different because they are reversible.
- The discomforts, risks, and benefits of the specific sterilization you are choosing.
- That you can change your mind at any time before surgery without losing any health services or federally funded benefits.
The form itself does not list specific medical side effects. Your provider explains those verbally based on the procedure.4U.S. Department of Health and Human Services. Consent for Sterilization – Form HHS-687 Ask questions before signing. The moment you sign, the 30-day clock starts.
Completing the Four Sections
Form F00090 has four distinct sections, each signed by a different person, each with its own date. Missing or mismatched dates are one of the most common reasons claims get rejected.
Patient Consent
Write your name, the name of the physician who will perform the procedure, and the specific method of sterilization (for example, “bilateral tubal ligation” or “vasectomy”). The form includes a statement that you are consenting freely, understand the procedure is permanent, and know you can withdraw consent at any time without losing Medicaid benefits.4U.S. Department of Health and Human Services. Consent for Sterilization – Form HHS-687 Sign and date. Your consent is valid for 180 days from this date.3Texas Medicaid & Healthcare Partnership (TMHP). F00090 – Sterilization Consent Form
Interpreter’s Statement
If you needed an interpreter, that interpreter signs and dates this section, confirming they translated the oral information and read the form to you in your language. If no interpreter was used, leave the section blank.
Statement of the Person Obtaining Consent
The nurse, physician’s assistant, or surgeon who counseled you signs here. Their signature confirms they explained the permanent nature of sterilization, discussed temporary alternatives, described risks and benefits, told you withdrawal will not affect your benefits, and that to the best of their knowledge you are at least 21 and mentally competent. This section also requires the facility name and address.4U.S. Department of Health and Human Services. Consent for Sterilization – Form HHS-687
Physician’s Statement
The physician who performs the surgery fills out this section on the day of the procedure, not before. Shortly before operating, the physician explains again that sterilization is permanent, reviews risks and benefits, and reminds you that you can still withdraw consent. The physician then signs, dates, and records the date of the operation. Auditors compare the physician’s date against your original signature date to confirm the waiting period was met.
The 30-Day and 180-Day Deadlines
At least 30 full days must pass between the date you sign and the date of surgery, and the procedure must take place within 180 days of your signature. If 180 days go by without surgery, you have to complete a new form and wait another 30 days.1eCFR. 42 CFR 441.253 – Sterilization of a Mentally Competent Individual Claims for procedures performed outside this window are routinely denied, and timing errors cannot be corrected after the fact.
Exceptions for Premature Delivery and Emergency Abdominal Surgery
The waiting period drops to 72 hours in two narrow situations. If you go into premature labor, you can consent to sterilization at that time only if you originally signed the form at least 30 days before your expected delivery date. For emergency abdominal surgery, 72 hours must pass between consent and the procedure. In either case, the physician has to document the specific emergency circumstances on the form.1eCFR. 42 CFR 441.253 – Sterilization of a Mentally Competent Individual No other situation shortens the wait.
How the Form Gets Submitted
You do not submit Form F00090 yourself. After surgery, your provider keeps the completed form in your medical record and attaches it to the claim sent to TMHP. Providers can fax it to TMHP at (512) 514-4229.3Texas Medicaid & Healthcare Partnership (TMHP). F00090 – Sterilization Consent Form TMHP checks that all four signatures are present, dates are consistent, the 30-day wait was satisfied, and you met the eligibility rules. Only then is the provider reimbursed.
If a claim is denied, the cause is almost always on the form itself: a missing date, a signature in the wrong section, an expired 180-day window, or a waiting period that fell short. Administrative errors can sometimes be corrected and the claim resubmitted. Timing violations cannot.
Withdrawing Consent
You can change your mind at any point before the surgery. The form states plainly that withdrawing consent will not result in the loss of any health services or benefits from federally funded programs.4U.S. Department of Health and Human Services. Consent for Sterilization – Form HHS-687 No provider, clinic, or Medicaid office can penalize you for stopping. Tell your provider.
If Medicaid Denies the Claim
You have the right to request a fair hearing to challenge a denial. The state must send you written notice explaining how to request a hearing and the deadline, which in most states falls between 30 and 90 days of the notice date.5Medicaid.gov. Understanding Medicaid Fair Hearings Requests can usually be made by mail or in person, and some states accept phone or online submissions. If you have an urgent medical need, ask for an expedited hearing. Contact the Texas Health and Human Services Commission or TMHP for the specific appeals steps in Texas.