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Order and Authorization Re Health Care and Education JU 02.0240 - Washington
| Order and Authorization Re Health Care and Education Form. This is a Washington form and can be used in Shelter Care Juvenile Court Statewide . |
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Superior Court of Washington County of _______________________ Juvenile Court No: Dependency of: Order and Authorization re Health Care and Education (ORHCE) D.O.B.: I. Basis The court has reviewed the record in this case and considered the need for information pertaining to the physical and mental health and the educational needs of the child in order to determine appropriate services and to provide for adequate care for the child who is the subject of this action. II. Findings Based on the record to date and on the court's determination that the child is in need of out-of-home placement, the court finds that authorization for release of information and for decision-making relating to the health care and educational needs of the child should be granted. III. Order The court Orders that the Department of Social and Health Services (DSHS) has the right to inspect and copy all health, medical, mental health, and education records of the above named child. Where required by state and federal law, the DSHS must obtain the child's consent. Any agency, hospital, doctor, nurse, dentist, orthodontist, or other health care provider, therapist, drug/alcohol treatment provider, psychologist, psychiatrist, or mental health clinic, or health/medical records custodian or document management company, or school or school organization shall permit the DSHS to inspect and to obtain copies of any records relating to the child involved in the case, without the further consent of the parent or guardian of the child. The court Further Orders that the DSHS or its designee shall have authority and responsibility, where applicable, to notify the child's school that the child is in out-of-home placement; enroll the child in school; request the transfer records; request and authorize evaluation of special needs; attend parent/teacher conferences; excuse absences; grant permission for extracurricular activities; authorize medications which need to be administered during school hours and sign for medical needs that arise during school hours; and complete or update school emergency contact records. Or/Auth re Health Care/Edu (ORHCE) - Page 1 of 3 WPF JU 02.0240 (11/2009) RCW 74.13.550 -.590 American LegalNet, Inc. www.FormsWorkFlow.com The court further authorizes DSHS to share and receive information about the child with the child's school and school district and with service providers in order to properly care for the child. The clerk shall provide certified copies of this order at no cost to the DSHS, at its request. Dated:______________________________ ______________________________________ _ Judge/Court Commissioner Presented by: Signature Print Name/Title WSBA No. Copy Received. Approved for entry, notice of presentation waived. Signature of Child [ ] Signature of Child's Lawyer Print Name WSBA No. [ ] Signature of Mother [ ] Pro Se, Advised of Right to Counsel [ ] Signature of Mother's Lawyer Print Name WSBA No. [ ] Signature of Father [ ] Pro Se, Advised of Right to Counsel [ ] Signature of Father's Lawyer Print Name WSBA No. [ ] Signature of Guardian or Legal Custodian [ ] Pro Se, Advised of Right to Counsel [ ] Signature of Guardian or Legal Custodian's Lawyer Print Name WSBA No. [ ] Signature of Child's GAL [ ] Signature of Lawyer for the Child's GAL Print Name Print Name WSBA No. Or/Auth re Health Care/Edu (ORHCE) - Page 2 of 3 WPF JU 02.0240 (11/2009) RCW 74.13.550 -.590 American LegalNet, Inc. www.FormsWorkFlow.com Signature of Agency Representative Signature of Agency Representative's Lawyer Print Name Print Name WSBA No. [ ] Signature of Tribal Representative [ ] Signature Print Name Print Name WSBA No. Lawyer for _______________________ State of Washington ) County of ____________________ ) SS I, _____________________ Clerk of the above entitled court, do hereby certify that the foregoing instrument is a true and correct copy of the original now on file in my office. In witness whereof, I hereunto set my hand and the seal of said court this ___________ day of _________________ 20 ______. ________________________, Clerk By _________________________________________, Deputy. Or/Auth re Health Care/Edu (ORHCE) - Page 3 of 3 WPF JU 02.0240 (11/2009) RCW 74.13.550 -.590 American LegalNet, Inc. www.FormsWorkFlow.com
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