DJJ Form HS020 "Parental Notification of Health-Related Care: General" - Florida

What Is DJJ Form HS020?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DJJ Form HS020 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form HS020 "Parental Notification of Health-Related Care: General" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
PARENTAL NOTIFICATION OF
HEALTH-RELATED CARE: GENERAL
N
Y
: ______________________________ D
B
: ____________
AME OF
OUTH
ATE OF
IRTH
F
N
: _______________________ DJJID#: __________ D
: __________
ACILITY
AME
ATE
P
/
:
ARENT
GUARDIAN NAME AND ADDRESS
DJJ F
:_________________________________________________________
ACILITY NAME AND ADDRESS
____________________________________________________________________________
Dear______________________________________:
Our records indicate that you are the parent or guardian who has authority over health care for the above
named youth. The purpose of this form is to notify you of changes in the health status of this youth.
The following health care treatment has been ordered or begun or the following health care event has
occurred:
_____________________________________________________
____ _____
_____________________________________________________
____ _____
________________________________________________________
______________________________________________ ____________________________________________
Signature of Health Care Provider
Printed Name of Person Completing Form
If you have any concerns about the above information or do not want your child to
receive this medication/treatment; notify the DJJ facility at the phone number indicated.
Phone Number:
_____
Person to Contact:
_______________
_________________
TO THE PARENT/GUARDIAN: IF THIS BOX IS CHECKED, THIS MEANS THAT YOU HAVE BEEN
NOTIFIED BY PHONE OF THE HEALTH CARE TREATMENT ABOVE. WE NEED YOU TO GIVE YOUR
CONSENT IN WRITING AND SEND THIS FORM BACK TO US AT THE FACILITY ADDRESS LISTED
ABOVE. YOUR SIGNATURE INDICATES THAT YOU GIVE YOUR PERMISSION FOR US TO
ADMINISTER THIS HEALTH CARE TREATMENT.
______________________
____________
Parent/Guardian Signature
Date
** Copy of Notification to be filed in Individual Health Care Record.
Save As
Reset/Clear Form
Print Form
020
FORM
P
1
1
AGE
OF
63M-2
. 1/2014
REV
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
PARENTAL NOTIFICATION OF
HEALTH-RELATED CARE: GENERAL
N
Y
: ______________________________ D
B
: ____________
AME OF
OUTH
ATE OF
IRTH
F
N
: _______________________ DJJID#: __________ D
: __________
ACILITY
AME
ATE
P
/
:
ARENT
GUARDIAN NAME AND ADDRESS
DJJ F
:_________________________________________________________
ACILITY NAME AND ADDRESS
____________________________________________________________________________
Dear______________________________________:
Our records indicate that you are the parent or guardian who has authority over health care for the above
named youth. The purpose of this form is to notify you of changes in the health status of this youth.
The following health care treatment has been ordered or begun or the following health care event has
occurred:
_____________________________________________________
____ _____
_____________________________________________________
____ _____
________________________________________________________
______________________________________________ ____________________________________________
Signature of Health Care Provider
Printed Name of Person Completing Form
If you have any concerns about the above information or do not want your child to
receive this medication/treatment; notify the DJJ facility at the phone number indicated.
Phone Number:
_____
Person to Contact:
_______________
_________________
TO THE PARENT/GUARDIAN: IF THIS BOX IS CHECKED, THIS MEANS THAT YOU HAVE BEEN
NOTIFIED BY PHONE OF THE HEALTH CARE TREATMENT ABOVE. WE NEED YOU TO GIVE YOUR
CONSENT IN WRITING AND SEND THIS FORM BACK TO US AT THE FACILITY ADDRESS LISTED
ABOVE. YOUR SIGNATURE INDICATES THAT YOU GIVE YOUR PERMISSION FOR US TO
ADMINISTER THIS HEALTH CARE TREATMENT.
______________________
____________
Parent/Guardian Signature
Date
** Copy of Notification to be filed in Individual Health Care Record.
Save As
Reset/Clear Form
Print Form
020
FORM
P
1
1
AGE
OF
63M-2
. 1/2014
REV