Form Dcf F Cfs2379 E PDF Details

Navigating the healthcare needs of children in welfare facilities requires careful consideration and consent, especially in the eyes of the Department of Children and Families’ Division of Safety and Permanence. The DCF-F-CFS2379-E form plays a pivotal role in this process, designed specifically to navigate medical service consent within child welfare facilities. This document, while voluntary, is crucial for ensuring that facilities comply with specific sections of the Wisconsin Administrative Code, namely DCF 52 and 57, which govern the administration of routine and emergency medical services to children in care. It encompasses sections that require detailed information about the facility, the child in care, and the parent or guardian, aiming to establish a clear line of consent for both routine medical services and emergency medical situations. Parents or guardians are required to complete this form, which remains valid throughout the child’s placement, ensuring that their child receives proper medical and dental examinations, treatments, and in emergency cases, necessary surgical procedures, all from licensed professionals. Additionally, the form addresses privacy concerns by stipulating that the personally identifiable information provided will be used solely for identification purposes and could be employed for secondary purposes under specific privacy laws. Respecting the guardians' ability to specify exclusions in the medical treatment and the robust effort to secure consent in emergencies highlight the form’s comprehensive approach to safeguarding the welfare and rights of children in care.

QuestionAnswer
Form NameForm Dcf F Cfs2379 E
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesDCF-F-CFS2379-E, examinations, precludes, dcf form print

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DEPARTMENT OF CHILDREN AND FAMILIES

Division of Safety and Permanence

MEDICAL SERVICES CONSENT – CHILD WELFARE FACILITIES

Use of form: Use of this form is voluntary. However, completion will help ensure compliance with DCF 52 and 57 of the Wisconsin Administrative Code. Personally identifiable information gathered on this form will be used for identification purposes only. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

Instructions: The authorization is to be completed by the parent or guardian of the child in care and shall be valid for the duration of that child’s placement. If additional space is required, attach separate sheet(s).

A.Facility Information

Name – Facility

Telephone Number – Facility

Address – Facility (Street, City, State, Zip Code)

B.Child Information

Name – Child (Last, First, MI)

Birthdate (mm/dd/yyyy)

Home Address – Child (Street, City, State, Zip Code)

C.Parent / Guardian / Legal Custodian Information

1. Name – Parent / Guardian / Legal Custodian

Address – Home (Street, City, State, Zip Code)

Telephone Number – Home

 

 

Address – Work (Street, City, State, Zip Code)

Telephone Number – Work

 

 

Address – Other

Telephone Number – Other

 

 

2.Name – Parent / Guardian / Legal Custodian

Address – Home (Street, City, State, Zip Code)

Telephone Number – Home

 

 

Address – Work (Street, City, State, Zip Code)

Telephone Number – Work

 

 

Address – Other

Telephone Number – Other

 

 

D. Routine Medical Services Consent and Exclusions

For purposes of routine medical services for the above-named child, I hereby give my consent for the above-named facility to approve the provision of routine medical services including medical and dental examinations and non-emergency prescribed treatments (e.g., tooth repair, immunizations, medications, reproductive health needs assessment). Note: Any medical examination or service provided shall be provided only by an individual licensed to perform the examination or service. Add any exceptions you may have to this provision in the space provided below.

DCF-F-CFS2379-E (R. 04/2010)

E. Emergency Medical Services Consent and Exclusions

In case of a medical emergency involving the above-named child, I understand that the following procedures will be used. I hereby give my consent for the facility to arrange for emergency medical services using the following procedures:

1.A reasonable effort will be made to contact me and secure my consent for needed medical services, including surgical procedures.

2.Verbal consent may be obtained in an emergency situation where time or distance precludes obtaining written consent. It shall be documented in the child’s record by indicating who obtained the consent, who gave the consent and that person’s relationship to the child, and what specific services are authorized by the consent. Verbal consent is valid for 10 calendar days, during which time there shall be a good faith effort to obtain written consent.

3.If I cannot be located within a reasonable time, the facility has the authority to consent to emergency medical services including surgery.

4.The juvenile court has the authority to consent to other medical services.

Note: Any medical examination or service provided shall be provided only by an individual licensed to perform the examination or service.

F. Signatures

Parent / Guardian / Legal Custodian

Date Signed

(Required for all residents under 18 years of age and any residents 18 years of age or older who have been deemed incompetent by a court.)

Resident

Date Signed

(Between 14 and 18 years of age – whenever feasible.)

Resident

Date Signed

(18 years of age or older – Required unless resident has been deemed incompetent by a court.)

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