Get Ccl 010 Authorization For Emergency Medical Care - Kdhe

The CCL 010 Authorization For Emergency Medical Care is a critical document that provides written consent for emergency medical treatment for a child or youth while they are in a care facility. This guide will help you complete the form accurately and efficiently online, ensuring that all necessary information is provided for the safety and well-being of your child.

Follow the steps to accurately complete the form online.

1. Click the ‘Get Form’ button to access the CCL 010 form online and open it in your preferred editor.
2. Enter the name of the facility exactly as it appears on the facility's license. Include the license number directly below it.
3. Provide the names of the individuals or staff members authorized to give consent for emergency medical care. Include any additional representatives if necessary.
4. Fill in the first and last name of the child or youth who will be receiving care in the designated section.
5. Specify the dates during which this authorization is valid, including the start and end dates.
6. Have a parent or guardian sign and date the form to provide their consent.
7. If required, a witness must sign and date the form as well.
8. Complete any necessary notarization if your local hospital or clinic requires it.
9. List any known allergies or pertinent medical information about the child or youth that should be known in case of an emergency.
10. Indicate whether the child is covered by health insurance by selecting 'Yes' or 'No.' If applicable, provide the insurance policy name and policy number.
11. Include any necessary medical assistance program details along with the card number.
12. If known, write down the date of the child's last Tetanus inoculation.
13. Ensure to have both the medical record/assessment form and the authorization for emergency medical care available when the child is transported by the facility.

Ensure your child's safety by completing the CCL 010 Authorization For Emergency Medical Care form online today.