Army Child And Youth Services Health Screening Form Page 2

Download a blank fillable Army Child And Youth Services Health Screening Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Army Child And Youth Services Health Screening Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Child/Youth Name
Date of birth (YYYYMMDD)
Age
Part F – Release of Information
I authorize ____________________________________(name of Medical Treatment Facility or physician’s practice) to release any medical information regarding my
child __________________________(name of child) to the ____________________________ (name of installation) Child & Youth Services (CYS) Special Needs
Accommodation Process (SNAP) personnel and their staff that is necessary to conduct SNAP review. This authorization will remain in effect for one year. I understand
I may revoke this consent in writing at any time before expiration, but any action taken by the SNAP on this authorization prior to revocation is valid and will remain in
effect.
I understand that information disclosed pursuant to this authorization is For Official Use Only (FOUO) and may be subject to redisclosure. I understand that information
redisclosed is no longer protected by DoD 6025, 18-R; however, confidentiality of this information will remain protected by the Privacy Act of 1974, 5 U.S.C. section
552a.
The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE Health Plan, enrollment
in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization.
___________________________________________________________
___________________________________
Printed Name and Signature of Parent/Personal Representative of Child
Date (YYYYMMDD)
Part G – Army Public Health Nurse (APHN) Review
Current Medications other than those listed on page 1:
Diagnosis: ________________________
Background/Notes:
Medical Records Reviewed?
□ No
□ Yes □ Not Available
Training for CYS Staff/Provider Required:
Recommendation Summary:
SNAP REQUIRED:
□ No SNAP required □ Modified □ Full □ Annual Review (No team meeting required)
Requirements Prior to Placement:
Medical Action Plan reviewed by APHN:
□ Respiratory □ Allergy □ Seizure
□ Diabetes □ Special Diet
□ Other__________________
APHN Printed Name or Stamp
APHN Signature
Date (YYYYMMDD)
Date Received by APHN
Date Returned to CER:
Form Updated: 11 Mar 09

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 3