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Family PACT and Medi-Cal Patients

Tubal ligation, Essure and vasectomy procedures are provided by Family PACT and Medi-Cal.

Effective February 1, 2006, Family PACT uses the Federal Sterilization consent form (PM 330), the same consent form used by the Medi-Cal program. This form can only be ordered (free of charge) through the Department of Health Services Central Warehouse Facility by calling 916-928-9203. 

• Instructions for ordering and completing the form (Word Document, Medi-Cal website)
• Medical Exam and History Forms (Family PACT website)
• Tutorial on counseling clients and completing the PM 330 form (Family PACT website)

Private Pay / Non-Family PACT Patients

Should you choose to use your Title X funds to support sterilization services, you must use the OMB federal sterilization consent forms. Forms are available online from the HHS website. Scroll down the page for PDF or Microsoft Word format.

The OMB Federal Sterilization Consent Form is expired.  There is an updated form going through the legal process and once it is released staff will be required to use the new version. CFHC will monitor the OPA website for updates and replace the former consent when the new version is available. Until that point, the older version of the form is approved for use. 

• HHS-687 Sterlization Consent form in English (HHS website)
• HHS-687-1 Sterilization Constent form in Spanish (HHS website)

Want to help out?

CFHC invites agencies to make their materials available to others throughout the Title X system. This can be arranged by contacting Dannelle Pietersz, NP, MSN, MPH, Medical Specialist, Clinical & Community Health Programs at 213-386-5614 x4546, email pieterszd@cfhc.org.