Fill and Sign the Tn Custody 497327001 Form

POWER OF ATTORNEY FOR CARE OF A MINOR CHILD Use of this form is authorized by T.C.A. § 34-6-301 et seq. Completion of this form, along with the proper signatures, is sufficient to authorize enrollment of a minor in school and to authorize medical treatment. However, a school district may require additional documentation/information as permitted by this section of Tennessee law before enrolling a child in school or any extracurricular activities. Please print clearly . NOTE: THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR CHILD’S HEALTH CARE AGENT BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOUR CHILD. USE OF THIS FORM IS OPTIONAL AND SHOULD BE CONSIDERED ONLY IF YOU ARE COMFORTABLE WITH THE POWERS AND PROVISIONS GRANTED BY THIS DOCUMENT. EXPLANATION: You have the right to name someone to make health care decisions for your child when you cannot make or communicate those decisions for whatever reason. This document gives the person you designate as the health care agent broad powers to make health care decisions for your child when you cannot make the decision yourself or cannot communicate your decision concerning your child to other people. Note : This Health Care Consent for a Minor meets the requirements of Tennessee law and is intended to be valid in any jurisdiction in which it is presented, but places outside of Tennessee may impose requirements that this form does not meet; therefore, if your child leaves this state we recommend that you seek assistance from an attorney in that area who can advise you on whether you need to sign another form of Authorization to Consent for the Health Care of Minor. Part I : To be filled out and/or initialed by parent(s). 1. Minor Child’s Name _____________________________________ 2. Mother/Legal Guardian’s Name & Address _____________________________________ _____________________________________ _____________________________________ 3. Father/Legal Guardian’s Name & Address _____________________________________ _____________________________________ 1 of 6 _____________________________________ 4. Caregiver’s Name & Address _____________________________________ _____________________________________ _____________________________________ 5. ( _____ ) Both parents are living, have legal custody of the minor child and have signed this document; OR ( _____ ) One parent is deceased; OR ( _____ ) One parent has legal custody of the minor child, and has sent by Certified Mail, Return Receipt requested, to the other parent at last known address, a copy of this document and a notice of the provisions in § 34-6-305; or the non-custodial parent has not consented to the appointment and consent cannot be obtained because _____________________________________ . 6. Temporary care-giving authority regarding the minor child is being given to the caregiver because of the following type of hardship ( check at least one ): (_____) the serious illness or incarceration of a parent or legal guardian; ( _____ ) the physical or mental condition of the parent or legal guardian or the child is such that care and supervision of the child cannot be provided; ( _____ ) the loss or uninhabitability of the child’s home as a result of a natural disaster; ( _____ ) the need for medical or mental health treatment (including substance abuse treatment) by the parent or legal guardian; or, ( _____ ) other (please describe) _____________________________________ 7. (_____) I/We undersigned, authorize the named caregiver to do one or more of the following: ( _____ ) enroll the child in school and extracurricular activities (including but not limited to Boy Scouts, Boys & Girls Club) ( _____ ) obtain medical, dental, and mental health treatment for the child, and ( _____ ) provide for the child’s food, lodging, housing, recreation and travel. 2 of 6 ( _____ ) I/We grant the following additional power to the named caregiver: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ . 8. ( _____ ) I/We understand that this document does not provide legal custody to the caregiver. If at any time I/we disagree with a decision of the named caregiver or choose to make any healthcare or educational decisions for my/our child, I/we must revoke the power of attorney, in writing, and provide written documentation to the health care provider and the local education agency (i.e., school). 9. ( _____ ) I/We understand that this document may be terminated in another written document signed by either parent with legal custody of by any order of a court with competent jurisdiction. Part II : To be initialed by caregiver. 10. ( _____ ) I understand that this document, properly executed, gives me the right to enroll the minor child in the local education agency serving the area where I reside. 11. ( _____ ) I understand that this document does not provide me with legal custody. 12. ( _____ ) I understand that, prior to enrollment, the local education agency may require documentation of the minor child’s residence with a caregiver and/or documentation or other verification of the validity of the stated hardship. 13. ( _____ ) I understand that, except where limited by federal law, I shall be assigned the rights, duties, and responsibilities that would otherwise be assigned to the parent, legal guardian or legal custodian pursuant to Tennessee Code Annotated Title 49. 14. ( _____ ) I understand that, if the minor child ceases to reside with me, I am required by law to notify any person, school or health care provider to whom I have given this document. Part III : To be initialed by parent(s) and caregiver. 15. ( _____ )( _____ ) We understand that, by accepting the power of attorney, if we enroll a student in a school system while fraudulently representing the child’s current residence or the parents’ hardship or circumstances for 3 of 6 using the power of attorney, either or both of us is liable for restitution to the school district for an amount equal to the per pupil expenditure for the district in which the student is fraudulently enrolled. Restitution shall be cumulative for each year the child has been fraudulently enrolled in the system and may include costs and fees related to litigation. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY CHILD’S PHYSICAL OR MENTAL HEALTH. A. General Grant of Power and Authority. Subject to any limitations in this Directive, my agent has the power and authority to do all of the following: (1) Request, review and receive any information, verbal or written, regarding my child’s physical or mental health including, but not limited to, medical and hospital records; (2) Execute on my behalf any releases or other documents that may be required in order to obtain this information; (3) Consent to the disclosure of this information; and (4) Consent to the donation of any of my child’s organs for medical purposes. B. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my child’s individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to my child, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my child’s individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my child’s health care providers to restrict access to or disclosure of my child’s individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my child’s health care provider. I/We declare under penalty of perjury under the laws of the State of Tennessee that the foregoing is true and correct. STATE OF TENNESSEE ) COUNTY OF ______________________ ) Date: ______________ Mother/Legal Guardian 4 of 6 The Mother/Legal Guardian, _____________________________________ , personally appeared before me this       day of _________________ , 20    . ________________________________ NOTARY PUBLIC My commission expires: __________________ STATE OF TENNESSEE ) COUNTY OF ______________ ) Date: ________________ Father/Legal Guardian The Father/Legal Guardian, _____________________________________ , personally appeared before me this       day of _________________ , 20    . ________________________________ NOTARY PUBLIC My commission expires: __________________ STATE OF TENNESSEE ) COUNTY OF ______________ ) Date: ________________ Caregiver The Caregiver, _____________________________________ , personally appeared before me this       day of _________________ , 20    . ________________________________ NOTARY PUBLIC My commission expires: __________________ 5 of 6 NOTICE TO THE LOCAL EDUCATION AGENCY AND/OR HEALTH CARE PROVIDER: Pursuant to T.C.A. § 34-6-308, no person, school official or health care provider who acts in good faith reliance on a power of attorney for care of a minor child to enroll the child in school or provide medical, dental, or mental health care, without actual knowledge of facts contrary to those authorized, is subject to criminal or civil liability to any person, or is subject to professional disciplinary action for such reliance. This section shall apply even if medical, dental, or mental health care is provided to a minor child or the child is enrolled in a school in contravention of the wishes of the parent with the legal custody of the minor child, as long as the person, school official or health care provider has been provided a copy of an appropriately executed power of attorney for care of a minor child, and has not been provided written documentation that the parent has revoked the power of attorney for care of a minor child. Additionally, pursuant to T.C.A. § 34-6-310, a person who relies on the power of attorney for care of a minor child has no obligation to make any further inquiry or investigation. Nothing in this part shall relieve any individual from liability for violations of other provisions of law. 6 of 6