Healthcare Adoption Application

HEALTHCARE ADOPTION APPLICATION

Agency Name:

APPLICANT INFORMATION

Date of Birth:     Gender: Male   Female   Other

HOUSEHOLD AND HOUSEHOLD MEMBERS

Primary Residence Type: Owned   Rented   Other

INSURANCE AND HEALTHCARE INFORMATION

MEDICAL AND MENTAL HEALTH HISTORY

History of psychiatric treatment or counseling: Yes   No
If yes, provide dates and treating provider(s):

Known infectious conditions (check all that apply):
HIV   Hepatitis   Tuberculosis   None

BACKGROUND, LEGAL AND SAFETY AUTHORIZATIONS

I authorize representatives of the agency to obtain criminal background checks, child welfare checks, and motor vehicle records for the purpose of suitability determination. I understand that any failure to disclose relevant information may be grounds for denial or revocation of placement. Initial to acknowledge:

Have you ever been convicted of a crime, or are there any pending criminal charges? Yes   No

I hereby authorize release of medical records, mental health records, and relevant treatment documentation to the agency to assist in evaluation for adoption suitability and ongoing care planning. This authorization is specific to records necessary for assessment and may include psychiatric, substance use, and infectious disease records. Initial to acknowledge:

HIPAA Authorization: I authorize covered entities to disclose protected health information to the named agency for purposes of evaluation and case management. This authorization permits disclosure of diagnosis, treatment, medication, and laboratory results as needed. Expiration date for this authorization:

REFERENCES

PLACEMENT PREFERENCES AND CAPABILITIES

I am applying to adopt: Infant (0-1)   Toddler (1-3)   Child (4-12)   Teen (13-18)

Willing to consider a child with medical or developmental needs: Yes   No

DOCUMENTS AND ATTACHMENTS

Please indicate all documents attached with this application:
Photo identification   Recent medical clearance   Proof of income/employment
Home environment photos   Reference letters   Other

ATTESTATION, CONSENT AND AGREEMENTS

I certify under penalty of perjury that the information provided in this application is true and complete to the best of my knowledge. I understand that incomplete or false statements may result in denial or rescission of adoption placement. I consent to necessary background checks, home visits, and medical record review as part of the evaluation and post-placement monitoring process.

I understand that acceptance of this application does not guarantee placement and that the agency retains sole discretion to approve, conditionally approve, or deny suitability for adoption based upon statutory requirements, agency policies, and the best interests of the child.

By signing below I authorize the agency to contact listed references, healthcare providers, and relevant agencies to verify information contained herein and to obtain records necessary for assessment of my suitability to adopt.

ADDITIONAL INFORMATION

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