Texas Dept of Family
and Protective Services
Form 2085-D
July 2008
Page 1
Attachment D
APPROVAL BY MEDICAL CONSENTER FOR PREVENTIVE MEDICAL CARE
OF CHILD IN DFPS CONSERVATORSHIP
The Texas Department of Family and Protective Services (DFPS), managing conservator of
Child’s DFPS IMPACT Person ID
Child's Name
Date of Birth
County
Name of Judge
Court No.
Medicaid No.
Cause No.
Phone Number of Court
has designated me (" the medical consenter “) to consent to the medical care for this child.
As medical consenter, I am providing my written consent for the provision of preventive
care for this child, unless the health care provider directs me to participate in the
appointment in person or by phone.
Preventive medical care is defined in the Medicaid Procedure Manual Section 40.1 as the
American Academy of Pediatrics Periodicity Schedule or Texas Health Steps medical
check-ups. The Periodicity Table includes:
 Well child examinations by the healthcare provider;
 Sensory screening (e.g., vision, hearing),
 Developmental/behavioral assessment,
 Immunizations,
 Laboratory testing for screening purposes (e.g., blood work, urinalysis, TB testing,
STD screening, pelvic exam),
 Anticipatory guidance, and
 Dental check ups.
If you have any concerns or determine that the child has a medical condition of a more serious
nature, please contact me at the number provided below.
Signature –Medical Consenter Section 1
Date
Telephone Number
Note to DFPS staff: Forms 2085 B, C and D are the only authorizations for medical care that the
child's DFPS caseworker and supervisor may sign without consulting the DFPS regional attorney.
Note to Health Care Providers: If you have any medical concerns regarding this child, please
contact the DFPS caseworker, supervisor (see contact information in the signature line above) or
the judge (see contact information in the heading on Page 1). The health care provider may
also notify the judge if he or she has any concerns about the decisions of the medical
consenter.