IN THE CIRCUIT COURT OF THE ______JUDICIAL CIRCUIT
IN AND FOR ______COUNTY, FLORIDA
FAMILY/JUVENILE DIVISION
Case No.
IN THE INTEREST OF )
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)
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DOB: )
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A CHILD )
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ORDER APPOINTING ATTORNEY AD LITEM TO REPRESENT CHILD IN MEDICAID FAIR HEARING
The Court hereby appoints ______as Attorney Ad Litem for the above captioned Child in a Medicaid Fair Hearing. It is further ordered that:
1. ______shall serve as Attorney Ad Litem for the Child, and shall be the attorney as to all matters concerning the Child’s receipt of medically necessary services pursuant to the Early Periodic Screening Diagnosis and Treatment (EDPSDT) provisions of federal Medicaid law, including representation of the Child in a Medicaid Fair Hearing, pursuant to 42 C.F.R. 431.200 et seq.
2. That upon presentation of this order to any agency, hospital, organization, school, person, or office, including the Clerk of this Court, the State of Florida Department of Children and Families, the Agency for Health Care Administration, the Agency for Persons with Disabilities, the Department of Juvenile Justice, Miami-Dade County School Board and any other School Board, human service agencies, pediatricians, psychologists, psychiatrists, and law enforcement agencies, representatives of ______are hereby authorized to inspect and copy any records and receive any information relating to the above named Child without the consent of the Department of Children and Families, the Agency for Health Care Administration, Department of Juvenile Justice or any other agency or person exercising custody or control over the Child, including the Child’s parent(s), regardless of the confidentiality or classification status of the records or information pursuant to state or federal law, including privacy provisions the Health Insurance Portability Accountability Act (HIPAA).
3. ______shall maintain information received from any such source as confidential and will not disclose the same except in Court and to other parties with the Child’s express consent. Staff of ______, including attorneys, legal interns, social work interns, doctors and expert consultants, shall further be permitted to have private attorney-client communications with the Child, and shall be allowed to visit, make telephone calls to and receive telephone calls from the Child at his or her foster home or other placement at any reasonable time without interference from any third party for the duration of the jurisdiction of this court.
4. In its capacity as Attorney Ad Litem for the Child, ______will provide legal services to the Child under the same traditional duties of undivided loyalty, confidentiality, and competent representation owed to an adult client, consistent with Rule 4-1.14 (a) of the Florida Rules of Professional Conduct and the ABA Standards of Practice for Lawyers Who Represent Children in Abuse and Neglect Proceedings.
5. ______shall be notified of any hearings, staffings, investigations, depositions, or other proceedings concerning the Child and shall be notified prior to any action taken on behalf of the Child by any party.
6. ______shall report to this Court on ______concerning the Attorney ad Litem’s efforts to advocate for the legal interests of the Child with respect to Child’s receipt of medically necessary treatment and services from the Department of Children & Families, the Agency for Health Care Administration and any medical providers.
DONE AND ORDERED at Miami-Dade County, Florida, this ______day of ______, 2008.
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CIRCUIT JUDGE
Clerk forward copies to:
Attorney(s)
DCF Attorney
Guardian ad Litem Program
Agency for Health Care Administration
Attorney ad Litem for Child
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