Form DCF-020 "Physician's Statement for Foster Care Application" - Connecticut

Form DCF-020 or the "Physician's Statement For Foster Care Application" is a form issued by the Connecticut State Department of Children and Families.

The form was last revised in June 1, 2017 and is available for digital filing. Download an up-to-date Form DCF-020 in PDF-format down below or look it up on the Connecticut State Department of Children and Families Forms website.

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Download Form DCF-020 "Physician's Statement for Foster Care Application" - Connecticut

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Connecticut Department of Children and Families
PHYSICIAN’S STATEMENT FOR FOSTER CARE APPLICATION
DCF-020
6/17 (Rev.)
Page 1 of 2
If additional writing space is needed, please write on back of form or attach an additional sheet.
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
I hereby authorize
, M.D., to release to the Department of Children and Families
The information requested below regarding myself as required by DCF regulations for foster care license applicants and their household members.
Applicant’s Name:
DOB:
Date of Last Examination:
Address: (No. and Street):
City:
State:
Zip:
Connecticut
Applicant’s Signature:
Date:
Has this person had any significant medical conditions (chronic or recent, including hospitalizations)?
Yes
No If yes, describe:
Does this person have a mental health diagnosis?
Yes
No If yes, describe:
Is this person prescribed any medications?
Yes
No If yes, describe below or attach a list.
Name of Medication
Dosage
Reason for Prescription
Connecticut Department of Children and Families
PHYSICIAN’S STATEMENT FOR FOSTER CARE APPLICATION
DCF-020
6/17 (Rev.)
Page 1 of 2
If additional writing space is needed, please write on back of form or attach an additional sheet.
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
I hereby authorize
, M.D., to release to the Department of Children and Families
The information requested below regarding myself as required by DCF regulations for foster care license applicants and their household members.
Applicant’s Name:
DOB:
Date of Last Examination:
Address: (No. and Street):
City:
State:
Zip:
Connecticut
Applicant’s Signature:
Date:
Has this person had any significant medical conditions (chronic or recent, including hospitalizations)?
Yes
No If yes, describe:
Does this person have a mental health diagnosis?
Yes
No If yes, describe:
Is this person prescribed any medications?
Yes
No If yes, describe below or attach a list.
Name of Medication
Dosage
Reason for Prescription
Page 2 of 2
Please give your impression of this person’s health status, both physical and emotional, and general prognosis for continued well-being. If this person is a child, is
the child up to date with immunizations?
Is this person free from communicable disease?
Yes
No. If no, please comment:
Do you consider this person’s physical and emotional condition satisfactory to provide foster care or to adopt a child?
Yes
No. If no, please comment:
SIGNATURE
Name of Physician:
Physician’s Signature:
Date:
Address: (No. and Street):
City:
State:
Zip:
Office Phone #:
E-mail:
SEND COMPLETED FORM TO:
Fax or mail copies to: Department of Children and Families FASU
Fax #:
Address:
Address 2:
City
State
Zip
Attention:
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