Healthcare Foster Care Management Form

HEALTHCARE FOSTER CARE MANAGEMENT FORM

Child Name:   Date of Birth:   Gender:

Placement and Agency Information

Placement ID:   Caseworker Name:   Caseworker Phone:

Foster Parent / Caregiver Information

Phone:   Alternate Phone:   Email:

Emergency Contact

Relationship:   Phone:   Alternate Phone:

Primary Care Provider / Medical Home

Provider Phone:   Provider Address:

Insurance / Payer Information

Policy / ID Number:   Group Number:   Subscriber Name:

Medical History and Current Health Status

Last Physical Examination:   Height:   Weight:

Immunizations

Consent to routine immunizations administered per state/local schedule:

Behavioral Health / Special Needs

Requires special accommodations (describe):

Permissions and Authorizations

The undersigned affirms that they are authorized to provide medical consent for the child named above, and authorize the following on behalf of the child in the absence of the placement agency or legal guardian:

  Authorization for routine medical, dental, and vision care, including well-child exams and preventive services.

  Authorization for emergency medical or surgical treatment if delay would endanger health; reasonable efforts will be made to contact caseworker and legal guardian.

  Authorization for caregiver to administer prescribed medications and over-the-counter treatments per provider directions.

  Authorization for caregiver to transport the child to scheduled medical appointments.

Release of Medical Information / HIPAA Acknowledgment

I authorize the release of medical records, immunization records, and treatment information related to the child named above to the placement agency, foster caregiver, and designated medical providers for purposes of continuity of care, case planning, and placement stability. This authorization includes behavioral health records when necessary for treatment coordination and safety planning.

Purpose of disclosure: Continuity of care, treatment, care coordination, and placement oversight. The recipient may use the information for these purposes only. I understand that this authorization is voluntary and may be revoked in writing except to the extent that actions have been taken in reliance on it.

Authorization expires on:    If left blank, this authorization will be valid for the duration of placement unless revoked in writing.

Additional Instructions / Care Plan Notes

Attachments included (medication list, immunization record, prior authorizations):

Certification and Acknowledgment

I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I represent that I have the legal authority to provide the consents and authorizations indicated herein for the child identified at the beginning of this form. I understand that this form does not amend legal custody arrangements and does not substitute for court orders limiting or defining parental rights.

I acknowledge that I have received a copy of this completed form and that I may revoke any authorization in writing, except to the extent that action has already been taken in reliance on this authorization.

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