Appalachian District Health Department

Policy and Procedure Policy Name Clinical Protocols and Procedures Policy Topic Women’s Preventive Health Clients Requesting Permanent Contraception

Section 500

Approved Date: 1-10-89

Chapter 522

Revised Date: 7-16-13

Purpose: To ensure that patients are referred to the appropriate provider if an interest is expressed in permanent contraception. Policy: It is the policy of Appalachian District to ensure appropriate referral for all patients requesting permanent contraception. Procedure: A. Females/ Males requesting permanent sterilization: 1. Clients must be age 21 or older. 2. Clients who have insurance, Medicaid, Family Planning Waiver, or other income is above the financial guidelines will be referred to a local OB-GYN of the patient’s choice. 3. Clients who do not have a funding source will be referred to DSS for enrollment for Family Planning Waiver. 4. Pregnant women who express interest in permanent sterilization or contraception will be provided with comprehensive education, the opportunity to complete informed consent and referred to delivering physicians office. 5. Counseling and consent process will ensure that the client’s decision to undergo sterilization is completely voluntary. 6. Women who qualify after receiving permanent sterilization may be followed through Primary Care. They will be offered annual physicals including a pap and breast exam. Men will be offered annual physicals. 7. Males who request permanent sterilization are referred to a local vasectomy clinic and or other source. 8. A letter indicating that the agency does not arrange for or pay for sterilizations will be submitted to the Central Office to the attention of Cheryl Lambeth, 1929 Mail service Center, Raleigh, NC 27699.

1|Clinical Protocols and Procedures – Women’s Preventive Health Clients Requesting Permanent Contraception