DHS-3762_6up SAMPLE FILE (1).pdf
PDF 2 MB Posted
- Attached to
- DHS 3762
- Solicitation number
- RFQ 171 260000000087 1
- Issued by
- Eaton County, Detroit City, Michigan
About this file
This is a medical consent form issued by the Michigan Department of Health and Human Services (MDHHS) that authorizes routine, non-surgical medical care and emergency medical or surgical treatment for minor children in foster care. The form, designated DHS-3762 (Revision 9-15), serves as a legal document that permits licensed or approved foster parents, institutions, agencies, or approved caregivers to secure necessary medical services for children placed in their care. The authorization covers routine medical care and emergency procedures but explicitly excludes non-emergency elective surgery, psychotropic medications, and clinical trials. The form requires completion of recipient identification, child information, caregiver details, and authorization signatures from both the caregiver and the MDHHS County Designee.
The form is designed for use at all health care provider appointments and must be presented by foster parents or caregivers at the time of each medical visit. Health care providers are instructed to contact the MDHHS County Designee for any additional information regarding the foster care child or youth. The document includes instructions for foster parents to inform healthcare facilities that the child is in foster care when scheduling appointments and to request caseworker contact information if it has not yet been provided for new placements. The MDHHS non-discrimination statement affirms the department's commitment to equal treatment regardless of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs, or disability.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| DHS 3762 REV 9-15 BID REQUEST 12-25 .docx | DOCX document | |
| Standard Contract Terms - Short Form.pdf | ||
| State of Michigan Print Mail Management Terms Conditions (1).docx | DOCX document |
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Text version
CONSENT TO ROUTINE, NON-SURGICAL MEDICAL CARE and
EMERGENCY MEDICAL/SURGICAL TREATMENT
State of Michigan Department of Health and Human Services
Recipient ID No. Date
Child Name Birth Date c Foster Parent, Institution or Agency or c Approved Caregiver Name
Authorized Signature
Title, Organization, or Relationship
Address Telephone Number
MDHHS County Designee (Print) Telephone Number is licensed or approved by the Michigan Department of Health and Human Services to provide foster care for children and is authorized to secure routine, nonsurgical medical care and emergency medical or surgical treatment for the above named minor child while placed in their care. Not included in this authorization are consents to:
nonemergency elective surgery, psychotropic medications and/or clinical trials.
DHS-3762 (Rev. 9-15) Previous edition obsolete.
CONSENT TO ROUTINE, NON-SURGICAL MEDICAL CARE and
EMERGENCY MEDICAL/SURGICAL TREATMENT
State of Michigan Department of Health and Human Services
Recipient ID No. Date
Child Name Birth Date c Foster Parent, Institution or Agency or c Approved Caregiver Name
Authorized Signature
Title, Organization, or Relationship
Address Telephone Number
MDHHS County Designee (Print) Telephone Number is licensed or approved by the Michigan Department of Health and Human Services to provide foster care for children and is authorized to secure routine, nonsurgical medical care and emergency medical or surgical treatment for the above named minor child while placed in their care. Not included in this authorization are consents to:
nonemergency elective surgery, psychotropic medications and/or clinical trials.
DHS-3762 (Rev. 9-15) Previous edition obsolete.
CONSENT TO ROUTINE, NON-SURGICAL MEDICAL CARE and
EMERGENCY MEDICAL/SURGICAL TREATMENT
State of Michigan Department of Health and Human Services
Recipient ID No. Date
Child Name Birth Date c Foster Parent, Institution or Agency or c Approved Caregiver Name
Authorized Signature
Title, Organization, or Relationship
Address Telephone Number
MDHHS County Designee (Print) Telephone Number is licensed or approved by the Michigan Department of Health and Human Services to provide foster care for children and is authorized to secure routine, nonsurgical medical care and emergency medical or surgical treatment for the above named minor child while placed in their care. Not included in this authorization are consents to:
nonemergency elective surgery, psychotropic medications and/or clinical trials.
DHS-3762 (Rev. 9-15) Previous edition obsolete.
CONSENT TO ROUTINE, NON-SURGICAL MEDICAL CARE and
EMERGENCY MEDICAL/SURGICAL TREATMENT
State of Michigan Department of Health and Human Services
Recipient ID No. Date
Child Name Birth Date c Foster Parent, Institution or Agency or c Approved Caregiver Name
Authorized Signature
Title, Organization, or Relationship
Address Telephone Number
MDHHS County Designee (Print) Telephone Number is licensed or approved by the Michigan Department of Health and Human Services to provide foster care for children and is authorized to secure routine, nonsurgical medical care and emergency medical or surgical treatment for the above named minor child while placed in their care. Not included in this authorization are consents to:
nonemergency elective surgery, psychotropic medications and/or clinical trials.
DHS-3762 (Rev. 9-15) Previous edition obsolete.
CONSENT TO ROUTINE, NON-SURGICAL MEDICAL CARE and
EMERGENCY MEDICAL/SURGICAL TREATMENT
State of Michigan Department of Health and Human Services
Recipient ID No. Date
Child Name Birth Date c Foster Parent, Institution or Agency or c Approved Caregiver Name
Authorized Signature
Title, Organization, or Relationship
Address Telephone Number
MDHHS County Designee (Print) Telephone Number is licensed or approved by the Michigan Department of Health and Human Services to provide foster care for children and is authorized to secure routine, nonsurgical medical care and emergency medical or surgical treatment for the above named minor child while placed in their care. Not included in this authorization are consents to:
nonemergency elective surgery, psychotropic medications and/or clinical trials.
DHS-3762 (Rev. 9-15) Previous edition obsolete.
CONSENT TO ROUTINE, NON-SURGICAL MEDICAL CARE and
EMERGENCY MEDICAL/SURGICAL TREATMENT
State of Michigan Department of Health and Human Services
Recipient ID No. Date
Child Name Birth Date c Foster Parent, Institution or Agency or c Approved Caregiver Name
Authorized Signature
Title, Organization, or Relationship
Address Telephone Number
MDHHS County Designee (Print) Telephone Number is licensed or approved by the Michigan Department of Health and Human Services to provide foster care for children and is authorized to secure routine, nonsurgical medical care and emergency medical or surgical treatment for the above named minor child while placed in their care. Not included in this authorization are consents to:
nonemergency elective surgery, psychotropic medications and/or clinical trials.
DHS-3762 (Rev. 9-15) Previous edition obsolete.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
DHS-3762 (Rev. 9-15) (Back) Previous edition obsolete.
Foster Parent/Caregiver: Provide the DHS-3762 to all health care providers at the time of the appointment. Inform the doctor/dentist office that the child is in foster care when making appointments. If this is a new placement and you have not yet received the name and contact information of the assigned caseworker, please contact the MDHHS County Designee listed on the front of this form.
Health Care Provider: If you are in need of additional information regarding this foster care child/youth, please contact the MDHHS County Designee listed on the front of this form.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
DHS-3762 (Rev. 9-15) (Back) Previous edition obsolete.
Foster Parent/Caregiver: Provide the DHS-3762 to all health care providers at the time of the appointment. Inform the doctor/dentist office that the child is in foster care when making appointments. If this is a new placement and you have not yet received the name and contact information of the assigned caseworker, please contact the MDHHS County Designee listed on the front of this form.
Health Care Provider: If you are in need of additional information regarding this foster care child/youth, please contact the MDHHS County Designee listed on the front of this form.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
DHS-3762 (Rev. 9-15) (Back) Previous edition obsolete.
Foster Parent/Caregiver: Provide the DHS-3762 to all health care providers at the time of the appointment. Inform the doctor/dentist office that the child is in foster care when making appointments. If this is a new placement and you have not yet received the name and contact information of the assigned caseworker, please contact the MDHHS County Designee listed on the front of this form.
Health Care Provider: If you are in need of additional information regarding this foster care child/youth, please contact the MDHHS County Designee listed on the front of this form.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
DHS-3762 (Rev. 9-15) (Back) Previous edition obsolete.
Foster Parent/Caregiver: Provide the DHS-3762 to all health care providers at the time of the appointment. Inform the doctor/dentist office that the child is in foster care when making appointments. If this is a new placement and you have not yet received the name and contact information of the assigned caseworker, please contact the MDHHS County Designee listed on the front of this form.
Health Care Provider: If you are in need of additional information regarding this foster care child/youth, please contact the MDHHS County Designee listed on the front of this form.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
DHS-3762 (Rev. 9-15) (Back) Previous edition obsolete.
Foster Parent/Caregiver: Provide the DHS-3762 to all health care providers at the time of the appointment. Inform the doctor/dentist office that the child is in foster care when making appointments. If this is a new placement and you have not yet received the name and contact information of the assigned caseworker, please contact the MDHHS County Designee listed on the front of this form.
Health Care Provider: If you are in need of additional information regarding this foster care child/youth, please contact the MDHHS County Designee listed on the front of this form.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
DHS-3762 (Rev. 9-15) (Back) Previous edition obsolete.
Foster Parent/Caregiver: Provide the DHS-3762 to all health care providers at the time of the appointment. Inform the doctor/dentist office that the child is in foster care when making appointments. If this is a new placement and you have not yet received the name and contact information of the assigned caseworker, please contact the MDHHS County Designee listed on the front of this form.
Health Care Provider: If you are in need of additional information regarding this foster care child/youth, please contact the MDHHS County Designee listed on the front of this form.
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