Healthcare Placement of Children Form

HEALTHCARE PLACEMENT OF CHILDREN FORM

Child Information

Date of Birth:   Gender:

Guardian / Placing Authority

Relationship to Child:   Phone:

Placement Facility / Agency

Medical / Insurance Information

Primary Care Physician:   Phone:

Policy Number:   Group Number:   Subscriber Name:

Medical History & Current Health

Immunizations up to date:   If not up to date, list missing immunizations below.

Placement, Treatment, and Authorization

I, the undersigned guardian or placing authority, authorize the named facility and its licensed medical staff to provide routine and emergency medical treatment to the child named above during the period of placement. This authorization includes examinations, diagnostic testing, immunizations, and administration of medications as necessary as described in the following specific consents.

Consent to routine medical care:   Consent to emergency treatment (including transport to emergency facility):

Consent to administration of prescription medications consistent with written orders from a licensed prescriber:   Consent to administration of over-the-counter medications according to facility policy:

Consent to mental health assessment and counseling services:   Consent to psychotropic medication only with separate written authorization:

Release of Information & HIPAA Acknowledgment

I authorize the release of the child's medical records, treatment summaries, and immunization records to the placement facility, affiliated care providers, and the placing authority identified on this form for the purpose of continuity of care. This authorization includes verbal and written communication necessary to coordinate services.

I acknowledge that I have been informed of the facility's privacy practices and understand that information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by privacy law. I further 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.

Authorization to release records to placement facility and to share information with care coordination entities:

Duration, Revocation, and Certification

This authorization is effective as of the placement start date and will remain in effect until the earlier of the child's discharge from the placement facility or the expiration date below, unless revoked in writing by the undersigned. Revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation.

Authorization Expiration Date:   If left blank, authorization is valid until discharge or written revocation.

Certification: By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand the nature of the authorizations granted herein, the risks and benefits of permitting medical treatment during placement, and my right to receive explanations of proposed treatment, to ask questions, and to request withdrawal of consent in writing.

Emergency Contact (Other than Guardian)

Relationship:   Phone:

Acknowledgments and Notices

The placing guardian acknowledges responsibility to provide accurate medical history and notify the facility of any changes in the child's health status. The facility will attempt to notify the guardian or emergency contact before major interventions when feasible; however, in emergencies the facility is authorized to act in the child's best interest to preserve health and safety.

The guardian understands that certain psychotropic medications may require additional review or separate consent; authorization for psychotropic medication will not be inferred solely from this general placement authorization unless expressly indicated above.

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