Get Newborn Hearing Screening Refusal Form (english) - Dshs State Tx

Filling out the Newborn Hearing Screening Refusal Form is an important process for parents and legal guardians who choose to decline the hearing screening for their newborn. This guide will provide clear and supportive instructions for completing the form online.

Follow the steps to complete the refusal form accurately and efficiently.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. In the first section, enter the name of the parent or legal guardian in the space provided. Clearly print the name to ensure accuracy.
3. Next, fill in the baby’s name in the designated field. This identifies the child for whom the hearing screening is being declined.
4. Fill in the name of the birthing facility in the corresponding line. This is the healthcare provider that typically conducts the hearing screening.
5. After completing the identifying information, review the release statement. This indicates that you are releasing the healthcare provider from fault regarding any disabilities or injuries that might have been identified through the screening.
6. Make sure to read the provided information regarding the newborn hearing screening thoroughly. This ensures that you understand the implications of your decision.
7. Print the name of the parent or legal guardian again in the specified area to confirm responsibility.
8. Provide your signature in the designated space. This signature serves as confirmation of your decision not to perform the hearing screening.
9. Enter the date of signing the form, which is important for the record.
10. Optionally, if there is a witness present, they may sign and date the form as well.
11. Lastly, save your changes to the document. You can then download, print, or share the form as needed to maintain the records.

Take the next step and complete the Newborn Hearing Screening Refusal Form online today.