Form CCL010 "Authorization for Emergency Medical Care" - Kansas

This version of the form is not currently in use and is provided for reference only.
Download this version of Form CCL010 for the current year.

What Is Form CCL010?

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

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL010 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL010 "Authorization for Emergency Medical Care" - Kansas

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Kansas Department of Health and Environment
CCL 010
Rev. 3/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Child Care Program:
(785) 296 -1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical
facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4-
582(e)(2).
Name of facility exactly as stated on the license.
License #
I hereby authorize _________________________________________________________ (Name of individual/staff member) and/or
____________________________________________________ (Name of individual/staff member) who is (are) representative(s) of the
above named facility to give consent for any and all necessary emergency medical care for my child or youth _____________________
___________________________________________ (First and Last Name of Child or Youth) while said child or youth is in said facility’s
custody between the dates of ___________________________ and ____________________________.
MM/DD/YYYY
MM/DD/YYYY
Signature of Parent or Guardian
Date Signed
Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic.
Date Signed
Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.
State of Kansas
County of ________________________
Signed or attested before me on ____________________ by______________________________________________.
MM/DD/YYYY
Name of Person
(Seal, if any.)
_______________________________________________
Signature of notarial officer
______________________________________________
Title (and Rank)
My appointment expires: __________________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency:
Is child covered by health insurance?  Yes  No
If yes, complete the following:
Health Insurance Policy Name _________________________________________ Policy Number ______________________
Medical Assistance Program ____________________________________________ Card Number________________________
Military Medical Care I.D. Number ___________________________________________________________________________
If known, date of last Tetanus inoculation: __________________________________
THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE
AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST ALSO
BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THE FACILITY.
Kansas Department of Health and Environment
CCL 010
Rev. 3/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Child Care Program:
(785) 296 -1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical
facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4-
582(e)(2).
Name of facility exactly as stated on the license.
License #
I hereby authorize _________________________________________________________ (Name of individual/staff member) and/or
____________________________________________________ (Name of individual/staff member) who is (are) representative(s) of the
above named facility to give consent for any and all necessary emergency medical care for my child or youth _____________________
___________________________________________ (First and Last Name of Child or Youth) while said child or youth is in said facility’s
custody between the dates of ___________________________ and ____________________________.
MM/DD/YYYY
MM/DD/YYYY
Signature of Parent or Guardian
Date Signed
Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic.
Date Signed
Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.
State of Kansas
County of ________________________
Signed or attested before me on ____________________ by______________________________________________.
MM/DD/YYYY
Name of Person
(Seal, if any.)
_______________________________________________
Signature of notarial officer
______________________________________________
Title (and Rank)
My appointment expires: __________________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency:
Is child covered by health insurance?  Yes  No
If yes, complete the following:
Health Insurance Policy Name _________________________________________ Policy Number ______________________
Medical Assistance Program ____________________________________________ Card Number________________________
Military Medical Care I.D. Number ___________________________________________________________________________
If known, date of last Tetanus inoculation: __________________________________
THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE
AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST ALSO
BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THE FACILITY.