Da 7625-1 - Army Child And Youth Services Health Screening Tool (Page 3 of 3) in pdf

Da 7625-1 - Army Child And Youth Services Health Screening Tool Page 3

16. Assistance with activities of daily living

Yes (explain)

17. Other conditions

Yes (specify and explain)

Part C - Medications

Child is on medications on a regular basis

Yes (If yes, please list medications and indicate which require administration during child

care hours.)

Part D - Early Intervention and Special Education

Child has an Individualized Family Service Plan (IFSP), Individualized Education Plan (IEP) or 504 plan

Yes

Part E - Exceptional Family Member Program (EFMP) Enrollment

Child is enrolled in the EFMP

Yes (specify for what condition)

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 CYS/SNAP in reliance

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.

Signature of Parent or Personal Representative of Child

Date (YYYYMMDD)

Page 3 of 3

DA FORM 7625-1, NOV 2006

APD V1.00

Da 7625-1 - Army Child And Youth Services Health Screening Tool Page 3