Dental examination form instructions

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MEDICAL RECORD PROCEDURES FOR FOSTER CAREGIVERS (Caregiver is a Foster Parent, Relative, Group Home, or FFA.)
The HEALTH & EDUCATION PASSPORT (HEP) BINDER accompanies each child at the time of placement. The Children’s Social Worker (CSW) will review the HEP BINDER with you at each visit.
The Health and Education Passport must be taken to all medical visits, including the initial examination visit. The health care provider must record all current medical services and tests on the DCFS 561(b). Please add the completed forms to the child’s HEP BINDER.
Immediately notify the child’s CSW (or Supervising CSW, if the CSW is unavailable) when there is any change in the child’s mental, medical and/or dental health that required urgent medical care.
If the child is removed from your care, the child’s complete HEP BINDER, including the Immunization Record, shall be returned to the CSW at the time of removal, as the HEP BINDER must accompany the child upon replacement.
Dental Care Examination Periodicity Schedule: Annual dental examination required at age 3 and above.
(To be completed by CSW/Caregiver. Please print legibly.)
 Child needs dental examination within thirty (30) days of initial placement.

 Child does not need dental examination because child had a dental examination within one (1) year of placement.

 Child needs dental examination by _______________.
CHILD’s NAME: ___________________________ DOB: __________ CASE #: ______________ DATE PLACED: __________
CAREGIVER: ___________________ (Phone) _______________ (FFA) ___________________ (Phone) _______________
CSW: __________________________ (File #) __________ (Phone) ____________________ (Fax) ____________________

Dental data entered into CWS/CMS by: (Name) _____________________________ (Date) _________________


DENTAL EXAMINATION FORM (To be completed by Dentist.)


Date of Dental Examination: _____________________ Name of Dentist: ___________________________________________

 Annual Required Examination

 Other/Follow-Up Visit

 Dentist’s own exam form is attached. If not attached, complete below.
Dental Exam results: (Treatment given; Medications Prescribed. Please attach copies of supporting documentation; test results, etc.)


(May be continued on additional pages if necessary. If so, provider to include child’s name and DOB, and sign and date additional pages.)
If follow-up care indicated, specify: __________________________________________________________________________

(Signature Stamp Required)

Signature of Health Care Provider: _________________________(Date)__________

Address: _______________________________________ Phone: _______________

DCFS 561(b) (Rev 07/02) Distribution: Pages 1, 2 and 3 to foster caregiver when child initially placed.

Page 4 to be filed in Psychological/Medical/Dental folder (purple).

DCFS 561(b) DENTAL EXAMINATION FORM When page 1 returned, file in Psychological/Medical/Dental folder.

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