Healthcare Lead Paint Form

HEALTHCARE LEAD PAINT EXPOSURE SCREENING & CONSENT FORM

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance Information

Medical History (relevant to lead exposure)

Lead Paint Exposure Screening Questions

Is the primary residence or daycare built before 1978?    Yes

Is there peeling, chipping, or deteriorating paint in the residence?    Yes

Have renovations, repairs, or remodeling been done within the last 6 months?    Yes

Does anyone in the household have a known elevated blood lead level or history of lead poisoning?    Yes

Is there a child under six years of age living in or visiting the residence?    Yes

Is there frequent hand-to-mouth behavior or pica in the patient (eating non-food items)?    Yes

Previous Testing

Has the patient had a prior blood lead test?    Yes   If yes, date of last test:   Result (if known):

Consent for Testing and Release

I authorize the healthcare provider to collect blood or other diagnostic specimens for lead testing and related laboratory analysis. I understand that the procedure involves a standard blood draw and that risks include brief pain, bruising, swelling, infection, or transient faintness. I understand the benefits include identification of lead exposure and guidance for treatment or environmental intervention.

I consent to the performance of blood lead testing:    Yes

If elevated lead levels are identified, I authorize the provider to initiate or recommend appropriate medical treatment and public health actions:    Yes

I understand that elevated blood lead levels are reportable to public health authorities and that the provider is required to report confirmed or suspected elevated results. I authorize release of test results to public health authorities for surveillance, case management, and environmental investigation:    Yes

I authorize the release of my test results and relevant clinical information to other treating healthcare providers involved in my care for purposes of diagnosis and treatment:    Yes

Privacy Acknowledgment

I acknowledge that I have been provided with the provider's privacy practices regarding the use and disclosure of my protected health information. I understand that my health information related to lead testing and results will be maintained in my medical record and may be disclosed as necessary to carry out public health reporting and case management as described above.    Acknowledged

Withdrawal: I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures already made pursuant to this authorization.

Certification: By signing below I certify that I am the patient or am authorized to consent on behalf of the patient. I have read and understand the information above, and my questions have been answered. I understand the provider's duty to report elevated lead results to public health authorities and consent to testing and disclosure as indicated above.

Sign Now