On March 26, 2018, the Department of Social Services (DSS) released Dss Form 2901 - Request for Authorization to Release Protected Health Information. The form is used to request authorization from a patient to release their protected health information to a third party. The form must be completed and signed by the patient, and can be submitted electronically or in paper format. The DSS website provides detailed instructions on how to complete and submit the form. Patients who wish to authorize the release of their protected health information should review the instructions carefully before completing and submitting the form.
| Question | Answer |
|---|---|
| Form Name | Dss Form 2901 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | dss form 2901 medical statement, dss 2901 form, dss form, dss form 2901 sc printable |
South Carolina Department of Social Services
Child Care Regulatory Services
MEDICAL STATEMENT
To be completed by staff, volunteers, and emergency personnel: |
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Name: |
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SSN: |
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Last |
First |
Middle |
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Home Address: |
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Number |
Street |
City |
State |
Zip |
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Date of Birth: |
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̈ Male ̈ Female |
Telephone: |
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Statement of your present health in your own words:
Have you ever had or do you now have any of the following:
Illness/Condition |
Yes |
No |
Illness/Condition |
Yes |
No |
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Vision Problems |
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Rupture or Hernia |
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Ear, Nose, Throat Problems |
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Hemorrhoids |
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Hearing Loss |
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Sugar or Albumen in Urine |
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Frequent/Severe Headaches |
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Jaundice |
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Dizziness or Fainting Spells |
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Diabetes |
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Head Injury |
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Heart Problems |
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Epilepsy or Seizures |
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Bone, Joint or other Deformity |
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Shortness of Breath or Lung Problems |
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Back Problems |
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Spitting up Blood |
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Tumor, Growth or Cancer |
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Tuberculosis |
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Nervous Condition |
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Skin Disease |
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Drug or Narcotic Habit |
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Pain or Pressure in Chest |
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Adverse Reaction to Medication |
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High Blood Pressure |
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Alcoholism |
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Frequent Indigestion |
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Illnesses or injury not mentioned above |
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Stomach, Liver or Intestinal Problems |
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Loss of consciousness |
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Have you ever been refused employment or been unable to hold a job for reasons of health? |
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Have you ever been denied life insurance? |
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Have you ever been rejected for or discharged from military service for physical, mental or other reasons? |
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If any item is checked “Yes”, please explain:
Please provide appropriate information below regarding freedom from tuberculosis (TB):
NEW EMPLOYEE: Enter below date of written evidence from a physician or health resource attesting you are free from
communicable TB.
Date of Verification
CURRENT EMPLOYEE: Check below if you are required to have additional tuberculosis tests.
̈ No more TB tests required |
̈ TB tests required every |
I CERTIFY THAT THE ABOVE INFORMATION SUPPLIED BY ME IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Signature |
Date |
DSS Form 2901 (OCT 07) Edition of JUL 82 is obsolete. |
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