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NJ DCF Logo with reverse copy 

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date: 9-29-1992

Volume:

X

Forms

Chapter:

A

Forms

Revised

Date: 6-28-2018

Subchapter:

1

Forms

Issuance:

5.50

CP&P Form 5-50, Health Care Provider Information Request Letter

 

 

 

Click here to view, print, or complete the CP&P Form 5-50, Health Care Provider Information Request Letter.

 

WHEN TO USE IT

 

The Health Care Provider Information Request Letter may be used to request basic health (medical/dental) information about a child under CP&P supervision when it is necessary to case assessment/planning. Use of this form letter is not mandatory.

 

HOW TO USE IT

 

Print this form using Local Office letterhead. The child’s name, NJS case number, date of birth, and the Case Manager’s name and telephone number are inserted by the Case Manager. The CP&P Form 5-50 is sent to the child’s health care provider for completion. Included with the form are a signed Authorization for Release of Information, CP&P Form 26-15, and a stamped addressed envelope for the form’s return. Enclose the CP&P Form 21-8, Certification of Documents. The returned, completed CP&P Form 5-50 is filed in the child’s case record after it has been reviewed.

 

 

DISTRIBUTION

 

Original                      -           Health Care Provider          

 

Copy                           -           Child’s Case Record