Please Complete a Form for Each Referral to Be Reviewed

Pre-Adoption Referral Information and Consent Form
Name of Clinic/Practice

(Please complete a form for each referral to be reviewed)

DEMOGRAPHIC INFORMATION

Name(s) of individual(s) requesting evaluation (If potential parents have different last names both names must appear on all correspondence, including telephone calls and materials submitted):

Prospective Parent One (agency/other please identify contact person):

______

Home Telephone: ______Work Telephone: ______
Cell Phone: ______Fax Number: ______
E-mail: ______

Prospective Parent Two:

______

Home Telephone: ______Work Telephone: ______
Cell Phone: ______Fax Number: ______
E-mail: ______

Address: ______
Street
______
City State County Zip Code

Referral Source: ______

Name of Adoption Agency/Attorney: ______

Name of Home Study Provider: ______

INFORMATION ON REFERRAL

Child's Name: ______Gender: ______
(as it appears on the medical information)

Date of Birth (if known): MM ______DD ______YY ______

Is this date of birth correct?
Certain _____ Fairly Certain _____ Not sure _____ Probably Not _____Definitely Not _____

If the date is inaccurate, what is the estimated birth date? ______

How was the estimated birth date determined? ______

Child's Birth Country: ______

Name of Orphanage (if applicable): ______

Length of time in orphanage/foster care: ______

List placements prior to foster care or orphanage and approximate length of time in each: ______
______
______

Prospective Parent _____
If you are a prospective parent how certain are you about adopting this child prior to evaluation?
Certain _____ Fairly Certain _____ Not Sure _____ Probably Not _____

If agency or other please identify reason for referral review:

______

CONSENT FOR PRE-ADOPTION EVALUATION

I/We, ______hereby consent to the review,
evaluation and assessment by the staff and faculty of the Name of Clinic/Practice ("the reviewers"), of ______("name of child as on the medical information"), a child currently available for adoption from ______(country of origin). I/We understand and agree that the reviewers include physicians, support personnel, trainees and technicians.

I/We have provided the reviewers with the following materials and documents:

No information: ______(ie: Travelling to the Ukraine)

Medical records: ______number of pages; translated by: ______

Video tape: ______length of recording ______date of recording
(please identify the child by some distinctive feature, e.g., clothing, length of or color of hair, gender, etc. * remember to follow labeling instructions)

Pictures: ______number of pictures

Other: ______

Please list any specific questions you may have about this child.
______
______
______
______

I/We understand that the materials (medical records, pictures and videotape) provided cannot be returned. These materials will be kept at the Clinic/Practiceas part of the permanent records.

I/We understand that the limitations of these evaluations include, but are not limited to, the following: the length of the video segment provided, language barriers, lighting, inability to interact with or examine the child, quality of translation of the medical records, the environment the child is in and the variability of the child's temperament. I/We understand that the reviewers will only review the video segments indicated on the initial client information sheet.

I/We understand that the results of the evaluation of the materials I/We provide constitute a professional opinion based on the limited information and cannot constitute a comprehensive and accurate diagnosis assessment of the child. I/We understand the impressions from the evaluation that I/We am/are requesting will not include a prediction of long term outcome because this is not a realistic expectation.

I/We further understand that Clinic/Practicecan not and will not provide a diagnosis of the health or prognosis of the child we seek to adopt. We recognize that a formal assessment can be rendered by Clinic/Practice only after a personal examination of the child and the administration and analyses of various physical, laboratory, psychological and psychomotor tests conducted on and with the child.

I/We also understand the medical records, pictures and videos will become part of the child's permanent record so that in the event of adoption and subsequent services, the medical records will be complete.

I/We understand that there are no separate billing codes provided by insurance companies to cover the unique pre -adoptive services that we are being offered. Our pre-adoptive evaluations are provided as a specialty service and as such are NOT covered within the codes recognized by most insurance companies. At this time we are not on any insurance plans and do not file claims with insurance companies. We further understand that payment for services is due at the time services are rendered.

I/We understand that the reviewer(s) and staff of the Clinic/Practicewill maintain confidentiality of the identity of the individuals/organization requesting the evaluation as well as the identity of the child to the best of our abilities.

HIPPA REGULATIONS

I give permission for appointment information to be (check all that apply):
☐Left on my home answering machine
☐Left on my work voice mail
☐Left on my cell phone voice mail
☐Left with the following person ______
☐Sent to the following e-mail address: ______
I give permission for lab results, medications, therapy recommendations or answers to my questions (check all that apply):
☐Left on my home answering machine
☐Left on my work voice mail
☐Left on my cell phone voice mail
☐Left with the following person ______
☐Sent to the following e-mail address: ______
☐Sent to the following fax number: ______

When leaving a telephone message the Clinic/Practicemay state:
☐This is ______from Dr. XXXX’soffice orClinic/Practice
☐This is ______from Name’s (no Dr Title) office

You may discuss this referral information with the following person(s) (if you would like relatives or friends to be your proxy when traveling please indicate at this time). We will not discuss any information with another person unless we have your written permission to do so. We recommend prior to travel identifying a point of contact and back-up contact person.
Name and relationship: ______
Name and relationship: ______

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I certify that I have been made aware of XXX’s Health System's Notice of Privacy Practices and that I have a right to receive a copy upon request. This Notice describes the type of uses and disclosures of my protected health information that might occur during my treatment, to facilitate the payment of my bills or in the performance of Clinic/Practice/Systemhealth care operations. The Notice also describes
my rights and Clinic/Practice/System’s duties with respect to my protected health information. I understand that copies of the Notice of Privacy Practices are available in the registration areas of each facility and on Clinic/Practice/System’s web site at I may request that a copy be mailed to me by calling xxx-yyy-zzzz.

Clinic/Practice/Systemreserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the above number and requesting a revised copy be mailed to me, by asking for one at the time of my next appointment, or by accessing Clinic/Practice/System’s web site listed above to view the most current version

By signing this form you acknowledge that you have read the above information and agree with the policies of the international adoption center as stated above.