Fill and Sign the Colorado Minor Form

 District Court  Denver Probate Court _________________________________County, Colorado Court Address: In the Interests of: Minor COURT USE ONLY Case Number: Division Courtroom ORDER APPOINTING EMERGENCY GUARDIAN FOR MINOR PURSUANT TO §15-14-204(5), C.R.S. Upon consideration of the Petition for Appointment of Emergency Guardian for the above minor and hearing on ________________________ (date), The Court finds, determines and orders: 1. Venue is proper. 2. Notice pursuant to § 15-14-204(5), C.R.S. was:  Reasonable.  Dispensed with because the Court finds from affidavit or testimony that the minor will be substantially harmed before a hearing can be held on the Petition. A. If the emergency guardian is appointed without notice, notice of the appointment shall be given within 48 hours after the appointment to the following: Name Relationship to Minor Minor if 12 years or older at time of mailing Parent Parent Person with care or custody if other than parent B. A hearing on the appropriateness of the appointment shall be held within five days after the appointment. The hearing will be held at the following time and location: Date: ________________________ Time: __________ Courtroom or Division: ____________ Address: ______________________________________________________________________ 3. The minor was born on _________________________ (date). 4. Following the procedures in § 15-14-201, et seq. is likely to result in substantial harm to the minor’s health or safety and no other person appears to have authority to act in the circumstances pursuant to §15-14-204(5), C.R.S. 5. The emergency guardianship cannot exceed 60 days from appointment. 6. The Court appoints the following person as emergency guardian for the minor: JDF 829 R6/13 ORDER APPOINTING EMERGENCY GUARDIAN FOR MINOR Page 1 of 2 Name: _________________________________________________________________________________ Street Address: __________________________________________________________________________ City: ___________________ State: ___ Zip Code: ________ Primary Phone #: _______________________ Mailing Address, if different:________________________________________________________________ Email Address: _______________________________ Alternate Phone #:________________________ 7. Letters of guardianship shall be issued. This emergency guardianship expires on _____________________ (date not to exceed 60 days from appointment.) The powers and duties of the emergency guardian are as follows:  To perform any and all acts necessary for the day-to-day care, custody, education, recreation, and property of the minor.  To access m inor’s medical records and information. The e mergency g uardian is deemed to be the m inor’s personal representative for all purposes relating to the m inor’s protected health information, as provided in HIPAA, Section 45 CFR 164.502(g)(2).  To authorize any and all medical and dental care for the health and well being of the minor. This care includes, but is not limited to, medical and dental exams and tests, x-rays, surgeries, anesthesia and hospital care.  To authorize mental health treatment, subject to § 27-10-107, C.R.S.  Other: _ _____________________ ___________________________________________________ 8. The Court further orders: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Date: __________________________ ______________________________________  Judge  Magistrate JDF 829 R6/13 ORDER APPOINTING EMERGENCY GUARDIAN FOR MINOR Page 2 of 2