DHS 107.06(3)(d)1. 1. The person who obtained consent for the sterilization procedure offered to answer any questions the individual to be sterilized may have had concerning the procedure, provided a copy of the consent form and provided orally all of the following information or advice to the individual to be sterilized:

DHS 107.06(3)(d)1.a. a. Advice that the individual is free to withhold or withdraw consent to the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss or withdrawal of any federally funded program benefits to which the individual might be otherwise entitled.

DHS 107.06(3)(d)1.b. b. A description of available alternative methods of family planning and birth control.

DHS 107.06(3)(d)1.c. c. Information that the sterilization procedure is considered to be irreversible.

DHS 107.06(3)(d)1.d. d. A thorough explanation of the specific sterilization procedure to be performed.

DHS 107.06(3)(d)1.e. e. A full description of the discomforts and risks that may accompany or follow the performing of the procedure, including an explanation of the type and possible effects of any anesthetic to be used.

DHS 107.06(3)(d)1.f. f. A full description of the benefits or advantages that may be expected as a result of the sterilization.

DHS 107.06(3)(d)1.g. g. Advice that the sterilization will not be performed for at least 30 days, except under the circumstances specified in par. (a) 4.

DHS 107.06(3)(d)2. 2. Suitable arrangements were made to ensure that the information specified in subd. 1. was effectively communicated to any individual who is blind, deaf, or otherwise disabled.

DHS 107.06(3)(d)3. 3. An interpreter was provided if the individual to be sterilized did not understand the language used on the consent form or the language used by the person obtaining consent.

DHS 107.06(3)(d)4. 4. The individual to be sterilized was permitted to have a witness of his or her choice present when consent was obtained.

DHS 107.06(3)(d)5. 5. The consent form requirements of par. (e) were met.

DHS 107.06(3)(d)6. 6. Any additional requirement of state or local law for obtaining consent, except a requirement for spousal consent, was followed.

DHS 107.06(3)(d)7. 7. Informed consent is not obtained while the individual to be sterilized is in any of the following situations:

DHS 107.06(3)(d)7.a. a. In labor or childbirth.

DHS 107.06(3)(d)7.b. b. Seeking to obtain or obtaining an abortion.

DHS 107.06(3)(d)7.c. c. Under the influence of alcohol or other substances that affect the individual’s state of awareness.

DHS 107.06(3)(e) (e) Consent form.

DHS 107.06(3)(e)1. 1. Consent shall be registered on a form prescribed by the department.

DHS 107.06 Note Note: A copy of the informed consent form can be found in the Wisconsin medical assistance physician provider handbook.

DHS 107.06(3)(e)2. 2. The consent form shall be signed and dated by:

DHS 107.06(3)(e)2.a. a. The individual to be sterilized;

DHS 107.06(3)(e)2.b. b. The interpreter, if one is provided;

DHS 107.06(3)(e)2.c. c. The person who obtains the consent; and

DHS 107.06(3)(e)2.d. d. The physician who performs the sterilization procedure.

DHS 107.06(3)(e)3. 3. The person securing the consent and the physician performing the sterilization shall certify by signing the consent form that:

DHS 107.06(3)(e)3.a. a. Before the individual to be sterilized signed the consent form, they advised the individual to be sterilized that no federally funded program benefits will be withdrawn because of the decision not to be sterilized;

DHS 107.06(3)(e)3.b. b. They explained orally the requirements for informed consent as set forth on the consent form; and

DHS 107.06(3)(e)3.c. c. To the best of their knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.