Dcfs 561 B Form PDF Details

Dcfs 561 b form is a document used to provide information about the child and family. This form is completed by caseworkers in the Illinois Department of Children and Family Services (DCFS). The information provided on this form helps to determine if a child is eligible for services from the department. The dcfs 561 b form is also used to assess the safety and well-being of children in need of protection or services. Completed forms are submitted to the central office for review.

QuestionAnswer
Form NameDcfs 561 B Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdcfs 561 c, dcfs examination form, medical examination form dcfs 561, form 561 dcfs

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COUNTY OF LOS ANGELES • DEPARTMENT OF CHILDREN AND FAMILY SERVICES

DCFS 561(b)

DENTAL EXAMINATION FORM - INSTRUCTIONS

MEDICAL RECORD PROCEDURES FOR FOSTER CAREGIVERS (Caregiver is a Foster Parent, Relative, Group Home, or FFA.)

The HEALTH & EDUCATION PASSPORT (HEP) BINDER accompanies each child at the time of placement. The Children’s Social Worker (CSW) will review the HEP BINDER with you at each visit.

The Health and Education Passport must be taken to all medical visits, including the initial examination visit. The health care provider must record all current medical services and tests on the DCFS 561(b). Please add the completed forms to the child’s HEP BINDER.

Immediately notify the child’s CSW (or Supervising CSW, if the CSW is unavailable) when there is any change in the child’s mental, medical and/or dental health that required urgent medical care.

If the child is removed from your care, the child’s complete HEP BINDER, including the Immunization Record, shall be returned to the CSW AT THE TIME OF REMOVAL, as the HEP BINDER must accompany the child upon replacement.

Dental Care Examination Periodicity Schedule: Annual dental examination required at age 3 and above.

(To be completed by CSW/Caregiver. Please print legibly.)

Child needs dental examination within thirty (30) days of initial placement.

Child does not need dental examination because child had a dental examination within one (1) year of placement. Child needs dental examination by _______________.

CHILD’s NAME: ___________________________ DOB: __________ CASE #: ______________ DATE PLACED: __________

CAREGIVER: ___________________ (Phone) _______________ (FFA) ___________________ (Phone) _______________

CSW: __________________________ (File #) __________ (Phone) ____________________ (Fax) ____________________

Dental data entered into CWS/CMS by: (Name) _____________________________ (Date) _________________

__________________________________________________________________________________________________________________

DENTAL EXAMINATION FORM (To be completed by Dentist.)

DENTAL EXAMINATION

Date of Dental Examination: _____________________ Name of Dentist: ___________________________________________

Annual Required Examination

Other/Follow-Up Visit

Dentist’s own exam form is attached. If not attached, complete below.

Dental Exam results: (Treatment given; Medications Prescribed. Please attach copies of supporting documentation; test results, etc.)

________________________________________________________________

________________________________________________________________

________________________________________________________________

(May be continued on additional pages if necessary. If so, provider to include child’s name and DOB, and sign and date additional pages.)

If follow-up care indicated, specify: __________________________________________________________________________

Signature of Health Care Provider: _________________________(Date)__________

 

 

(Dentist)

 

Address: _______________________________________ Phone: _______________

 

 

 

(Signature Stamp Required)

 

 

 

DCFS 561(b) (Rev 07/02)

Distribution: Pages 1, 2 and 3 to foster caregiver when child initially placed.

 

Page 4 to be filed in Psychological/Medical/Dental folder (purple).

DCFS 561(b) DENTAL EXAMINATION FORM

When page 1 returned, file in Psychological/Medical/Dental folder.

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