Youth’s Name ________________________________________________ Date ______________________

CONSENT FOR HEALTH CARE SERVICES
I, the undersigned legal guardian of the above named youth authorize professional health care providers employed or contracted by the Department of Human Services, Division of Youth Corrections, to provide general and emergency health care services, or to seek such services from other health care providers licensed to practice in the State of Colorado for the above named youth. These services shall include but not be limited to medical, dental, psychological, and psychiatric care. A reasonable effort will be made to promptly notify in case of serious illness, serious injury or emergency hospitalization. Consent will be obtained from me for elective surgical treatment or special procedures as required by other agencies prior to completion of the procedure.
In the event treatment is necessary for the youth , this letter, a copy of, or a facsimile authorizes representation of DHS/DYC to secure the necessary care required for the preservation of the youth’s well being.
It is my understanding that this consent is in effect as long as the youth remains or is in the physical or legal custody of the Department of Human Services, Divisions of Youth Corrections. I understand that I may revoke this authorization at any time except to the extent that action has already been taken to comply with it.
I understand that all the information collected regarding this youth may be used for research audit, or program evaluation purposes. No identifying information will be used in reporting data unless prior consent is obtained.

CONSENT FOR IMMUNIZATIONS
I, the undersigned legal guardian of the above named youth, authorize professional health care providers employed or contracted by the Department of Human Services, Division of Youth Corrections, to provide immunizations, to include Tetanus, Polio, Measles, Mumps, Rubella, Hepatitis A and B vaccines, as required by law for the above named youth. I have had an opportunity to ask any questions related to the risks of this youth having the immunizations.

Youth’s Signature _______________________________________________ Date ____________________
Witness/Position _______________________________________________ Date ____________________

Legal Guardian’s Signature (if youth is under age 18)____________________ Date ____________________
Witness/Position _______________________________________________ Date ____________________

MEDICAL INSURANCE INFORMATION
Medical Insurance Company or Plan___________________________________________________________
Policy/ Plan Number ________________________________Group __________________________________
Name of the Insured ________________________________Social Security or ID#_____________________

CONSENT FOR IMMUNIZATIONS RECORDS
The DHS/DYC Health Services Department requests that parents/guardians provide this facility with a copy of this youth’s immunization record. If you need to request these from the last school attended, you may have them fax a copy to this facility to the attention of the Medical Services Department. I agree to assist in providing a copy of these records to this agency.

Legal Guardian Signature (if youth is under age 18) ____________________ Date ____________________
Witness/Position ________________________________________________ Date ____________________

CONSENT TO RECEIVE HEALTHY SEXUALITY EDUCATION
I, the undersigned legal guardian, authorize the attendance of the above named youth at prevention-based education the area of healthy sexuality and reproduction.

Legal Guardian Signature (if youth is under age 18) _____________________ Date ____________________
Witness/Position _________________________________________________ Date ____________________

Department of Human Services
Division of Youth Corrections
Consent for Health Care Services

This fax message and any included attachments, from the Colorado Department of Human Services, are confidential and intended solely for the use of the individual or entity to which it is addressed. The information contained herein may include protected health information or otherwise privileged information. Unauthorized review, forwarding, printing, copying, distributing, or using such information is strictly prohibited and may be unlawful. If you received this message in error, please notify the sender by replying to this message and dispose of this fax without disclosure. Thank you.