Order Authorizing Medical And Dental Care And Limited Release Of Information {JC-E-365}

JC - E - 365 Effective 9/6/2013 Revised 07/01/2016 ORDER AUTHORIZING MEDICAL AND DENTAL CARE AND LIMITED RELEASE OF INFORMATION FOR CHILDREN PLACED BY THE JUVENILE COURT IN OUT - OF - HOME CARE Page 1 of 2 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO FOR COURT USE ONLY STREET ADDRESS: 3341 Power Inn Road MAILING ADDRESS: William R. Ridgeway Family Relations Courthouse CITY AND ZIP CODE: Sacramento, CA 9582 6 BRANCH NAME: SITTING AS THE JUVENILE COURT CHILD222S NAME: CHILD222S DATE OF BIRTH: ORDER AUTHORIZING MEDICAL AND DENTAL CARE AND LIMITED RELEASE OF INFORMATION FOR CHILDREN PLACED BY THE JUVENILE COURT IN OUT-OF-HOME CARE (Welfare & Institutions Code section 369 and Health and Safety Code section 1530.6) CASE NUMBER: DEPT. NO.: A. AUTHORIZATION: The Sacramento County Department of Child, Family and Adult Services and any of the Department222s duly appointed foster parents or caretakers, including relative caretakers, are hereby authorized to secure and consent to: 1. Routine medical and dental care for the above-named child. Such care shall include, but is not limited to: a) medical examination and treatment; b) surgical diagnosis; c) X-ray examination; d) local anesthetic; and shall be rendered to the child only upon advice of, and under the general or special supervision of a licensed physician, surgeon, dentist and/or other clinical experts. B. EXCEPTIONS: The following services are not covered under this Order and require a separate consent or court order: 1. Surgical procedure and hospital care: may be authorized by the parent or by court order if the parent does not consent. 2. The ongoing, non-emergency administration of psychotropic medication to dependent children in out-of-home care: must be authorized by court order in accordance with Welfare & Institutions Code section 369.5. 3. HIV testing: may be authorized by the parent, the youth if the youth is age 12 or older, or by court order if the parent does not consent. The social worker, in consultation with the attending physician and surgeon, may authorize HIV testing for infants less than 12 months of age, in accordance with Health and Safety Code section 121020. 4. Any medical or dental services for a nonminor dependent: requires consent by the nonminor dependent. American LegalNet, Inc. www.FormsWorkFlow.com JC - E - 365 Effective 9/6/2013 Revised 07/01/2016 ORDER AUTHORIZING MEDICAL AND DENTAL CARE AND LIMITED RELEASE OF INFORMATION FOR CHILDREN PLACED BY THE JUVENILE COURT IN OUT - OF - HOME CARE Page 2 of 2 Child222s Name: Case Number: C. NOTICE TO PARENTS AND COUNSEL: In any event where such routine medical, dental or other remedial care is provided, the Sacramento County Department of Child, Family and Adult Services shall inform the Child222s attorney, the Child222s parent/guardian, and the parent/guardian222s attorney what care or treatment was provided and what, if any, further care is scheduled for the Child. D. RELEASE OF INFORMATION: The Sacramento County Department of Child, Family and Adult Services is authorized to receive medical or dental health records of the child relating to medical or dental health services authorized pursuant to this Order not otherwise protected by confidentiality or privilege. Any medical or dental care obtained in accordance with minor consent laws is protected and shall not be released or further disseminated without informed consent of the child. SO ORDERED. This order is effective until terminated or modified by court order or until one year from the date of this order, whichever is earlier. Date Judge/Referee American LegalNet, Inc. www.FormsWorkFlow.com