Fill and Sign the Fillable Online Prior Authorization Request Form Az

Special Note in Completing Form: Items 1 through 4 must be completed to comply with MCL 700.5205(2). Each custodial parent who signs this plan is agreeing to all the conditions of the plan even though each item refers to a single person. When more than one parent enters into this agreement and they differ from one another in any area of the plan, each parent must complete their own plan on separate forms. For example: • If they differ in their reasons for the guardianship, each parent must specify their own reasons. This plan modifies a limited guardianship placement plan previously approved by the court. As custodial parent, I desire to establish a limited guardianship for my child and agree to the following plan: 1. The reason I want a limited guardianship is: To enable my child to attend school in the proposed guardian's school district. To provide health insurance through the proposed guardian. I will be or am incarcerated until . I am currently without housing adequate for my child. I am unable to care for my child because of my health. I am unable to care for my child because of my mental instability. I desire an alternative to action recommended by child protective services. I have lost substantial control of my child's behavior. I need to improve my parenting skills. The minor's physical needs for food, clothing, and housing may best be met by the proposed guardian. To comply with the requirement of the Reserves. Armed Forces. Other: 2. Visits and contact with my child will be sufficient to maintain my parent and child relationship and will be as follows: I will visit my child on: (please circle each day you plan to visit) Su M Tu W Th F Sa from: (please specify the time and circle either a.m. or p.m.) a.m. p.m. to a.m. p.m. I will visit my child times each week. month. Visits will occur at my residence. the proposed guardian's residence. . Telephone contact will take placedaily. weekly.monthly. . Letters will be sentdaily. weekly.monthly. . I will attend my child's school conference provided I receive timely notice of the conference. I will attend counseling with my child. I will participate in and arrange positive outings with my childdaily. weekly.monthly. . I will provide transportation for my child for . I will attend all doctor/dental appointments for my child (excluding emergencies). Transportation to and from visits with my child will be the responsibility of . Collect telephone calls will be accepted at number . Other: SEE OTHER SIDE FOR REMAINING PLANS PC 652 (9/05) LIMITED GUARDIANSHIP PLACEMENT PLAN In the matter of JIS CODE: LGP Approved, SCAO FILE NO. , a minor MCL 700.5205(2), MCR 5.404(A), (B) Judge Date Approved: Do not write below this line - For court use only LIMITED GUARDIANSHIP PLACEMENT PLAN STATE OF MICHIGAN PROBATE COURT COUNTY CIRCUIT COURT - FAMILY DIVISION 3. Financial support will be made by me as follows: Health insurance coverage through . Policy numbers are . School lunch money, clothing, supplies. Car insurance. $ each month for room, board, miscellaneous expenses to be paid at month'send. beginning. I will pay for counseling. I will pay for transportation to and from visits. I will provide food for my child as follows: I will pay for babysitting as follows: Other: 4. My plan is for the limited guardianship to continue until: The end of the current school year. I graduate my child graduates from high school. I am able to provide a drug-free household. I complete parenting classes. I am no longer incarcerated. on parole/probation. I am gainfully employed. I have established myself in a new residence. I have successfully completed drug or alcohol inpatient/outpatient treatment. I have cooperated with a substance abuse assessment and have followed the recommendations of the assessment. I have cooperated with a psychological evaluation and have followed the recommendations of the assessment. I have successfully completed psychological counseling. My child can accept my parental authority. I complete my G.E.D. job training. I no longer cohabitate with individuals. I cooperate with a domestic assault program. I have health insurance coverage for my child. I have completed my obligation to the Reserves or Armed Forces. Other: 5. I also agree as follows: As a custodial parent of the minor, I understand that if I substantially fail, without good cause, to follow this plan, my parental rights may be terminated by the court through proceedings under the juvenile code. Agreement and Acceptance of Appointment by Limited Guardian I will serve as limited guardian of the minor. I agree with this plan, and I accept the appointment and agree to file reports and to perform all duties required by law. Telephone no.Telephone no. City, state, zip Address Name of proposed guardian (type or print) Signature Date Date Signature Name of proposed guardian (type or print) Address City, state, zip Date Address Signature Name of custodial parent (type or print) City, state, zip Name of custodial parent (type or print) Signature Date Telephone no. Address Telephone no. City, state, zip Date of birth Driver license no. or other identification Date of birth Driver license no. or other identification