Army Child And Youth Services Health Screening - Tool #1 Page 2
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1
2Child/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
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