Genesis Youth Crisis Center, Inc.
DBA: Alta Vista Children’s Shelter
P.O. Box 546 ~ 261 Haymond Highway ~ Clarksburg, WV 26302
Phone (304) 622-3339 ~ Fax (304) 622-3433
MEDICAL CARE AND TREATMENT AUTHORIZATION
FOR CHILD IN RESIDENTIAL PLACEMENT
Resident Name ________________________________
Admission Date ___________
The child named above has been placed with a facility of Genesis Youth Crisis Center, Inc. by
the WV Department of Health and Human Resources. Having custody/guardianship of this child,
DHHR hereby grants Genesis Youth Crisis Center, Inc. the right to sign for the following:
1.
Emergency Medical Treatment;
2.
Routine visits to EPSDT provider or other medical provider for necessary medical
services;
3.
Psychological assessment and/or counseling/therapy services deemed necessary for the
child's treatment while in placement;
4.
Immunizations recommended by WV DHHR or medical provider;
5.
Hospitalization of the child for routine medical treatment as may be deemed necessary by
the child's physician;
6.
Release of medical and assessment information related to the child.
Genesis Youth Crisis Center, Inc. SHALL NOT sign for surgical procedures unless a life
threatening emergency situation exists.
Genesis Youth Crisis Center, Inc. will notify the DHHR social worker immediately of any
emergency, accident, serious illness, or hospitalization of the child.
Signed,
_____________________________________
________________________
Department of Health and Human Resources
Date