Consent for Medical /Surgical
Care and Treatment
, a minor, was committed to
the custody and guardianship of the Department of Human Services by order of the Circuit Court of
County on
Pursuant to ORS 419B.376(1) (dependency), the Department of Human Services as guardian of the
child’s person, does hereby consent to the following surgical/medical procedure:
and other medical treatment prescribed by Dr.
which, in
his/her opinion is in the best interest of the child. The Department of Human Services further
consents to the admittance of the child into
hospital selected by the above-listed doctor and the use of general, local, or spinal anesthesia as
specified by the doctor.
Caseworker Name:
Phone Number:
Supervisor Name:
Phone Number:
After Hours Emergency Contact Number:
THIS DOCUMENT ONLY PROVIDES CONSENT FOR THE ABOVE-STATED PROCEDURE. IT
DOES NOT CONSTITUTE AUTHORIZATION FOR PAYMENT.
The medical provider is directed to follow the Office of Medical Assistance Program medical guides.
(Prior authorization for payment may be required.)
Department of Human Services
at,
Policy Ref: i-B.1.4
Distribution: Copy to Originating Branch
, Oregon.
CF 242 (11/05)