DSHS Form 14-431 "Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)" - Washington

What Is DSHS Form 14-431?

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

Form Details:

  • Released on August 1, 2014;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Somali;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of DSHS Form 14-431 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 14-431 "Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)" - Washington

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DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)
VOLUNTARY PLACEMENT SERVICES
Medical / Dental Services Authorization
Licensed Providers: Please take this form with you when seeking emergency or routine medical / dental services for
children who are receiving Voluntary Placement Services from the Developmental Disabilities Administration and are in
your care.
,
This is to confirm that
CHILD’S NAME
DATE OF BIRTH
is receiving Voluntary Placement Services with the Developmental Disabilities Administration, Department of Social and
Health Services.
The birth / adoptive parent or legal guardian authorizes
LICENSED PROVIDER
to obtain and sign for routine and emergency medical and dental examination and care, as recommended by the child’s
treating licensed health care provider. This routine care includes well child examinations, immunizations, visual and/or
auditory screening, and routine ill child care as well as regular dental examinations and treatments.
Non-emergency care (for example, counseling and treatment, surgery, HIV testing, insertion of ear tubes, neurological
examinations, orthodontics, etc.) must have prior approval and requires consultation with the birth / adoptive parent or
legal guardian.
PARENT / GUARDIAN’S SIGNATURE
TELEPHONE NUMBER
DATE
LICENSED PROVIDER’S SIGNATURE
TELEPHONE NUMBER
DATE
DSHS/DDA SOCIAL WORKER’S SIGNATURE (WITNESS)
TELEPHONE NUMBER
DATE
This form was written in accordance with RCW 7.70.065 – Informed Consent – Section 2(a)(iv).
In the event of an emergency involving this child, it is the responsibility of the licensed provider to immediately
call the birth/adoptive parent or guardian listed above and the Developmental Disabilities Administration (DDA),
Voluntary Placement Services (VPS) / Social Worker.
DSHS 14-431 (REV. 08/2014)
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)
VOLUNTARY PLACEMENT SERVICES
Medical / Dental Services Authorization
Licensed Providers: Please take this form with you when seeking emergency or routine medical / dental services for
children who are receiving Voluntary Placement Services from the Developmental Disabilities Administration and are in
your care.
,
This is to confirm that
CHILD’S NAME
DATE OF BIRTH
is receiving Voluntary Placement Services with the Developmental Disabilities Administration, Department of Social and
Health Services.
The birth / adoptive parent or legal guardian authorizes
LICENSED PROVIDER
to obtain and sign for routine and emergency medical and dental examination and care, as recommended by the child’s
treating licensed health care provider. This routine care includes well child examinations, immunizations, visual and/or
auditory screening, and routine ill child care as well as regular dental examinations and treatments.
Non-emergency care (for example, counseling and treatment, surgery, HIV testing, insertion of ear tubes, neurological
examinations, orthodontics, etc.) must have prior approval and requires consultation with the birth / adoptive parent or
legal guardian.
PARENT / GUARDIAN’S SIGNATURE
TELEPHONE NUMBER
DATE
LICENSED PROVIDER’S SIGNATURE
TELEPHONE NUMBER
DATE
DSHS/DDA SOCIAL WORKER’S SIGNATURE (WITNESS)
TELEPHONE NUMBER
DATE
This form was written in accordance with RCW 7.70.065 – Informed Consent – Section 2(a)(iv).
In the event of an emergency involving this child, it is the responsibility of the licensed provider to immediately
call the birth/adoptive parent or guardian listed above and the Developmental Disabilities Administration (DDA),
Voluntary Placement Services (VPS) / Social Worker.
DSHS 14-431 (REV. 08/2014)