Healthcare Child Care Letter

HEALTHCARE CHILD CARE LETTER

Child Name:    Date of Birth:

Parent/Guardian Name:

Child Care Provider / Facility:    Facility Address:

Provider Information

Medical Summary and Orders

The undersigned parent/guardian provides the following medical information and authorizations for the benefit of the child while under the care of the named child care facility. This information is provided to assist staff in meeting medical needs and responding to emergencies.

  Up to date      Partial / Incomplete      Unknown

Medication Administration Authorization

I authorize trained child care staff to administer the medications listed below according to the prescriber’s directions and the facility's medication administration policies. I understand that medication must be provided in the original container with instructions from the pharmacy or prescribing provider.

Medication Start Date:    Medication End Date (if applicable):

Refrigeration Required:   Yes

Restrictions, Accommodations, and Special Instructions

Emergency Authorization

In the event of a medical emergency involving the child, I authorize the child care facility and its designated agents to obtain emergency medical treatment (including transport to a medical facility), to consent to necessary medical care if I cannot be reached, and to provide the treating provider with pertinent health information. This authorization is limited to the needs of the child while under facility supervision.

Authorize emergency transport and treatment:   Yes

HIPAA and Release of Information

I authorize the release of my child's protected health information to the child care facility and its staff for the limited purpose of medical care, medication administration, emergency response, and implementation of accommodations. This authorization is voluntary and limited in scope and duration as noted below. I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Insurance Information

Acknowledgment and Release

By signing below I certify that the information provided on this form is accurate and complete to the best of my knowledge. I authorize the release of relevant medical information to the facility and its health personnel as described above. I agree to hold the facility and its employees harmless for following the instructions herein, except where negligence or willful misconduct is demonstrated. I understand that this letter does not substitute for emergency medical care when required.

Provider Certification (to be completed by treating provider, optional)

The treating provider may complete the fields below to document orders or clarify the child's care needs. This section may be completed on provider letterhead and attached if more detailed documentation is required.

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