Fill - Free fillable HEALTH FACILITY MINOR RELEASE REPORT (California) PDF form

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

HEALTH FACILITY MINOR RELEASE REPORT

Prepare original and 3 copies: one copy each for hospital file, birth parent, and person receiving minor. SEE INSTRUCTIONS ON REVERSE SIDE

Send original to: California Department of Social Services

744 P Street, M/S 19-67

Sacramento, California 95814

(Within 48 hours as required by Health & Safety Code Section 1283)

IMPORTANT NOTICE

THIS HEALTH FACILITY RELEASE FORM IS NOT A RELINQUISHMENT FOR OR CONSENT TO ADOPTION.

IN CALIFORNIA, A BIRTH PARENT MAY PLACE A CHILD FOR ADOPTION BY AN:

1) Agency Adoption: The birth parent relinquishes the child to a licensed private or public adoption agency for the agency to place the child wi

th a family that has been

approved for adoption. If the birth parent and agency agree, the relinquishment may name the prospective adoptive parents. Before the relinquishment is filed with the

California Department of Social Services, the birth parent may cancel the relinquishment and reclaim the child. After the relinquishment is filed with the California

Department of Social Services, the birth parent will no longer have any right to the custody of the child, unless either (1) the agency agrees to allow the birth parent to

cancel the relinquishment and arrange to return the child to the birth parent, or (2) the relinquishment named the prospective adoptive parents and the adoption is not

completed..

2) Independent Adoption: The birth parent selects and places the child directly with the prospective adoptive parents. If the prospective adoptive parent is an adult not

related to the child, the birth parent must first be advised of his or her rights regarding an independent adoption by an Adoption Service Provider and then sign an

Independent Adoption Placement Agreement. The Independent Adoption Placement Agreement becomes an irrevocable consent to adoption after 30 days. During the

30-day period, the birth parent may revoke the agreement and reclaim the child or may waive the right to revoke the agreement. The birth parent must be interviewed

by a representative of the California Department of Social Services or a delegated county adoption agency before signing a waiver of the right to revoke the

Independent Adoption Placement Agreement.

A birth parent may place a child in foster care with an agency or with a person. Within six months, the birth parent must either sign a relinquishment, consent, an Independent

Adoption Placement Agreement, or reclaim the child. If the birth parent fails to take any of these actions, the court could find the child has been abandoned and issue an

order terminating the birth parent’s parental rights to the child and order a plan of adoption for the child.

I. IDENTIFYING INFORMATION

Child's Name_

_________________________________________________________

Birthdate

____________________

Gender

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Male

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Female

II. PARENT'S AUTHORIZATION (Fill out completely before parent signs. Alterations or deletions invalidate form).

_______________________________________________

, the parent of

_________________________________________________________

authorize

____________________________________________________________________________________

Hospital to release my child to

_____________________________________

residing at (complete address)

_______________________________________________________

for the purpose of

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Independent Adoption by (full names)

______________________________________________________________

residing

at (address)

______________________________________________________________

who has/have my permission to care for my child in

his/her/their home,

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Agency Adoption planning,

Foster Care,

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Other, Explain

_______________________________________

. This

authorization only releases my child from the hospital. It is not a consent to or relinquishment for adoption. I retain all parental rights to the custody

and control of my child. If the child is placed for Independent Adoption, I will be interviewed by a social worker from the California Department of

Social Services or a delegated county adoption agency after the prospective adoptive parents file the adoption petition with the Superior court.

B. MEDICAL AUTHORIZATION

I authorize and empower the person(s) named in Section II A above to make any provisions for medical and surgical care for my child identified on

this report, including anaesthesia, which may be deemed necessary or advisable by any licensed physician, for a period not to exceed six months

from the date of my child's release from this hospital.

______________________________________________

(Witness)

_______________________

(Date)

___________________________________________

(Signature of parent, or person having legal custody of child)

III. ACKNOWLEDGEMENT BY PERSON(S) RECEIVING CHILD

On (date)

____________________

I/we received (child's name)

_________________________________

for the purpose of

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Independent Adoption,

■ Agency Adoption planning, ■ Foster Care, ■

Other, as explained above. If the child is released for Independent Adoption and an adoption petition

is not filed within 30 days, the California Department of Social Services will begin an investigation to determine if a foster care licensing law is being

violated.

I/we understand that this authorizes only the release of this child from the hospital. This is not a consent or relinquishment of this child for adoption.

(Witness) (Date) (Signature of persons receiving child)

(Organization - if Applicable)

(Address)

Identification of person(s) receiving child (two ID's required):

Driver's license number

_______________________

State

________________

Social Security number or

other identification

_________________________________________________

Telephone number (________)___________________________________

IV. REPORT OF HOSPITAL

(Name of Hospital) (Address)

(Name of Attending Physician) (Mother's Admission Date) (Discharge Date)

(Mother's Name) (DOB) (Mother's Address)

(Father's Name)

(DOB) (Father's Address)

(Signature of Administrator or Designated Representative)

AD 22 (7/02)

INSTRUCTIONS FOR COMPLETING THE HEALTH FACILITY MINOR RELEASE REPORT

This form shall be completed for each child under 16 years of age who is discharged from a health facility to a person other than the child's

parent, relative by blood or marriage, or person having legal custody unless the child is transferred to another health facility or comes within

Sections 300, 601 or 602 of the Welfare and Institutions Code and is released to an agent of a public welfare, probation or law enforcement

agency.

Section I. Enter the child's name, birthdate and sex (as shown on the "Record of Live Birth" (VS 10) if the child is a newborn).

Section II.. The name and address of the person(s) or agency authorized by the parent or guardian to remove a child from the health facility

and, if an independent adoption, the name and address of the person(s) with whom the child will be placed must be entered in the

appropriate space before the parent or guardian signs the authorization.

Section III. The person(s) or agency receiving the child shall be the same as the person or agency designated by the parent or guardian in

Section II.

Section IV. Complete the entire section. If the father's name is unknown or withheld, this should be indicated.

A copy of the Health Facility Minor Release Report shall be offered to both parent or guardian and the person(s) removing the child from the

health facility as all persons are entitled to copies of any documents they may sign. If the copy is refused, this should be noted and retained

in the health facility file with the health facility copy.

CALIFORNIA LAW REGARDING RELEASE OF MINOR FROM HEALTH FACILITY

Section 1283 of the Health and Safety Code states:

"(a) No health facility shall surrender the physical custody of a minor under 16 years of age to any person unless such surrender is

authorized in writing by the child's parent, the person having legal custody of the child, or the caregiver of the child who is a relative of the

child and who may authorize medical care and dental care under 6550 of the Family Code.

"(b) A health facility shall report to the California Department of Health Services, on forms supplied by the department, the name and address

of any person and, in the case of a person acting as an agent for an organization, the name and address of the organization, into whose

physical custody a minor under the age of 16 is surrendered, other than a parent, relative by blood or marriage, or person having legal

custody. This report shall be transmitted to the department within 48 hours of the surrendering of custody. No report to the department is

required if a minor under the age of 16 is transferred to another health facility for further care or if this minor comes within Section 300, 601,

or 602 of the Welfare and Institutions Code and is released to an agent of a public welfare, probation, or law enforcement agency."

CALIFORNIA LAW REGARDING PLACEMENT OF CHILDREN

Section 8609(b) of the Family Code states:

"Any person, other than a birth parent, or any organization, association, or corporation that, without holding a valid and unrevoked license to

place children for adoption issued by the department [of Social Services], places any child for adoption is guilty of a misdemeanor."

CALIFORNIA LAW REGARDING TERMINATION OF PARENTAL RIGHTS

Section 7820 of the Family Code in part states:

"A proceeding may be brought under this part for the purpose of having any child under the age of 18 years declared free from the custody

and control of either or both parents if the child comes within any of the following descriptions set out in this chapter.”

Section 7822 of the Family Code in part states:

“(a) A proceeding under this part may be brought where the child . . . has been left by both parents or the sole parent in the care and custody

of another for a period of six months . . . without any provision for the child’s support, or without communication from the parent or parents,

with the intent on the part of the parent or parents to abandon the child.”

"(d) If the parent has placed the child for adoption and has not refused to give the required consent to adoption, evidence of the adoptive

placement shall not in itself preclude the court from finding an intent on the part of that parent to abandon the child. If the parent has placed

the child for adoption and has refused to give the required consent to adoption but has not taken reasonable action to obtain custody of the

child, evidence of the adoptive placement shall not in itself preclude the court from finding an intent on the part of that parent to abandon the

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Fillable HEALTH FACILITY MINOR RELEASE REPORT (California)

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