Form DCF-2101-S "Certification of a Child With Complex Medical Needs for Subsidized Adoptions and Subsidized Guardianships" - Connecticut

What Is Form DCF-2101-S?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2014;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • 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 printable version of Form DCF-2101-S by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-2101-S "Certification of a Child With Complex Medical Needs for Subsidized Adoptions and Subsidized Guardianships" - Connecticut

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DCF-2101-S
11/2014 (New)
State of Connecticut
Department of Children and Families
CERTIFICATION OF A CHILD WITH COMPLEX MEDICAL NEEDS
FOR SUBSIDIZED ADOPTIONS AND SUBSIDIZED GUARDIANSHIPS
Annual Review
Biennial Review
Date of Birth:
Child’s Name:
DCF Staff: Follow this Hyperlink for Descriptions of the Terms Below
Section I.
To be completed by the child’s PRIMARY HEALTH CARE PROVIDER. Check the corresponding box that most closely describes the needs of the
above named child at this time.
1. Potential Condition-Related Risk refers to a child who has chronic health conditions which are under good control but which require an educated caregiver.
Chronic diseases in this category include but are not limited to well-controlled seizure disorders, mild or moderate persistent asthma, cancer in remission or until
medical clearance by provider based on standards of practice, chronic conditions under good control such as Hepatitis C, latent TB or those receiving treatment,
and well-identified allergies which require Epi-pen use. Also included are newborns with peri-natal substance exposure requiring medications upon discharge and
premature infants (<32 weeks).
2. Medically at Risk refers to a child who has chronic health conditions which may periodically become life threatening. Well controlled insulin dependent
diabetes, moderate to severe asthma that has not resulted in a PICU or acute hospitalization in the last 6 months
3. Intensive Medical Needs refers to a child with chronic condition that is not well controlled and/or requires daily or regular intensive medical follow-up or
treatment. These include severe forms of chronic disease such as poorly controlled insulin dependent diabetes or those utilizing insulin pumps, seizure disorder,
hemophilia, immune disorder and/or severe persistent asthma which may require intensive and ongoing medical follow-up, or may have required acute
hospitalization or PICU admission in the past year. Children with diabetes requiring insulin pumps are included.
4. Technology Dependent or Medically Dependent
Technology Dependent refers to children who require mechanical devices or special technological interventions to maintain or sustain life. Children in
this category will require routine or periodic assistance from trained or licensed nursing personnel. Additionally, they will require the availability of
professional skilled nursing personnel for assessment of their medical status. Examples include children who require substantial assistance with
activities of daily living, those unable to ambulate independently due to cerebral palsy or developmental disabilities This also includes children who may
be temporarily unable to ambulate independently due to an injury or surgery with the expectation what they would be considered medically complex
temporarily and removed once they no longer require this degree of assistance
----- OR -----
Medically Dependent refers to children whose medical status requires specially trained personnel immediately available to attend them. In addition skilled
professional nursing assessment may be needed as frequently as every two hours and be 24/7 available to them. Such children may be able to live outside of a
hospital or medical care facility, but are dependent on a high level of care and assessment in order to sustain life. Included in this category are children with
tracheostomies and those on ventilators.
MEDICAL DIAGNOSES:
PRIMARY HEALTH CARE PROVIDER’S CERTIFICATION OF COMPLEX MEDICAL NEEDS:
I certify that this child requires the care checked above.
I certify that this child currently requires none of the care listed above.
Signature
Print Name
Date
Date of Evaluation by Primary Health Care Provider:
Section II.
To be completed by Department of Children and Families
Nurse Signature (if applicable)
Date
Subsidy Worker Signature
Date
Subsidy Supervisor Signature
Date
Next Review Date:
DCF-2101-S
11/2014 (New)
State of Connecticut
Department of Children and Families
CERTIFICATION OF A CHILD WITH COMPLEX MEDICAL NEEDS
FOR SUBSIDIZED ADOPTIONS AND SUBSIDIZED GUARDIANSHIPS
Annual Review
Biennial Review
Date of Birth:
Child’s Name:
DCF Staff: Follow this Hyperlink for Descriptions of the Terms Below
Section I.
To be completed by the child’s PRIMARY HEALTH CARE PROVIDER. Check the corresponding box that most closely describes the needs of the
above named child at this time.
1. Potential Condition-Related Risk refers to a child who has chronic health conditions which are under good control but which require an educated caregiver.
Chronic diseases in this category include but are not limited to well-controlled seizure disorders, mild or moderate persistent asthma, cancer in remission or until
medical clearance by provider based on standards of practice, chronic conditions under good control such as Hepatitis C, latent TB or those receiving treatment,
and well-identified allergies which require Epi-pen use. Also included are newborns with peri-natal substance exposure requiring medications upon discharge and
premature infants (<32 weeks).
2. Medically at Risk refers to a child who has chronic health conditions which may periodically become life threatening. Well controlled insulin dependent
diabetes, moderate to severe asthma that has not resulted in a PICU or acute hospitalization in the last 6 months
3. Intensive Medical Needs refers to a child with chronic condition that is not well controlled and/or requires daily or regular intensive medical follow-up or
treatment. These include severe forms of chronic disease such as poorly controlled insulin dependent diabetes or those utilizing insulin pumps, seizure disorder,
hemophilia, immune disorder and/or severe persistent asthma which may require intensive and ongoing medical follow-up, or may have required acute
hospitalization or PICU admission in the past year. Children with diabetes requiring insulin pumps are included.
4. Technology Dependent or Medically Dependent
Technology Dependent refers to children who require mechanical devices or special technological interventions to maintain or sustain life. Children in
this category will require routine or periodic assistance from trained or licensed nursing personnel. Additionally, they will require the availability of
professional skilled nursing personnel for assessment of their medical status. Examples include children who require substantial assistance with
activities of daily living, those unable to ambulate independently due to cerebral palsy or developmental disabilities This also includes children who may
be temporarily unable to ambulate independently due to an injury or surgery with the expectation what they would be considered medically complex
temporarily and removed once they no longer require this degree of assistance
----- OR -----
Medically Dependent refers to children whose medical status requires specially trained personnel immediately available to attend them. In addition skilled
professional nursing assessment may be needed as frequently as every two hours and be 24/7 available to them. Such children may be able to live outside of a
hospital or medical care facility, but are dependent on a high level of care and assessment in order to sustain life. Included in this category are children with
tracheostomies and those on ventilators.
MEDICAL DIAGNOSES:
PRIMARY HEALTH CARE PROVIDER’S CERTIFICATION OF COMPLEX MEDICAL NEEDS:
I certify that this child requires the care checked above.
I certify that this child currently requires none of the care listed above.
Signature
Print Name
Date
Date of Evaluation by Primary Health Care Provider:
Section II.
To be completed by Department of Children and Families
Nurse Signature (if applicable)
Date
Subsidy Worker Signature
Date
Subsidy Supervisor Signature
Date
Next Review Date: