Form P-2 Authorization for Medical, Dental, and Mental Health Car

OMB 0970-0554 [valid through MM/DD/20YY]

Administration for Children & Families

Office of Refugee Resettlement

Authorization for Medical, Dental, and Mental Health Care

This child is an unaccompanied alien child in the care and custody of the U.S. Department of Health and Human Services, Administration for Children and Families, Office of Refugee Resettlement (ORR). This document outlines who can consent for the child’s healthcare services on behalf of ORR, the need for ORR to receive all health records, and how to submit claims for reimbursement.

ORR is responsible for overseeing and ensuring the care of unaccompanied alien children until they can be safely released to a vetted sponsor, such as a parent or legal guardian or other family member.^[1] While in ORR care, these children are placed in federally funded Programs that act on behalf of ORR to coordinate the delivery of timely and appropriate healthcare services, as defined in the Unaccompanied Children Bureau Foundational Rule (45 CFR part 410). See also 6 U.S.C 279 and 8 U.S.C. 1232.

AUTHORIZATION TO CONSENT

Child’s Full Name: _________________________________________________ Date of birth: ____ /____ /_____

Alien Number: _ _ _ - _ _ _ - _ _ _ _

ORR hereby authorizes the Program, _________________, to consent for all elements of the above child’s initial medical exam and immunizations. In addition, ORR authorizes the Program to consent to all other healthcare services for this child except in the following circumstances:

• State law requires the child to consent for their own care.

• State law requires alternative consent procedures for psychotropic medication (as defined by the Texas Psychiatric Drug Formulary).

• Parenting minors who are authorized to consent for their children.

• The child is recommended to undergo a non-emergency elective health intervention that poses a substantial risk, such as a surgical procedure requiring sedation. ORR terms these types of services “Serious Medical services requiring heightened ORR involvement” and requires additional ORR oversight and authorization: a care provider may not approve or consent for such services without express approval from ORR. Per UAC Policy Guide Section 3.4.3 Requests for Healthcare Services, including Medical Services Requiring Heightened ORR Involvement.

HEALTH RECORDS

ORR must receive all health records for services provided to children in custody. The Program above and its representatives are authorized by ORR to receive all health records related to the care of this child, including specialty referrals and hospitalizations. ORR requires completion of all necessary government health assessment forms and requests the delivery of all other health records by the conclusion of services.

FINANCIAL RESPONSIBILITY & CLAIMS SUBMISSION

ORR is financially responsible for all healthcare services provided to this child. Reimbursement for healthcare services is administered by Point Comfort United (PCU) at the Medicare rate or as agreed upon with PCU. A standard health insurance identification card is not used for these services. The aforementioned Program and its representative are not financially responsible for any of the child’s healthcare expenses.

Healthcare claims should be mailed to PCU at:

PO Box 211628 Eagan, MN 55121

EDI Payer ID: PCU01

Please direct questions about ORR’s health and prescription drug benefit program, to PCU at clinical@pointcomfort.com.

Thank you,

___________________________________________________

Printed Name of ORR Director

___________________________________________________ ____ / ____ / ______ __________________

Signature of ORR Director Date Contact Number

___________________________________________________

Printed Name of Care Provider Authorized Representative

_______________________________________________ ____ / ____ / ______ __________________

Signature of Care Provider Authorized Representative Date Contact Number

^[1] On March 1, 2003, the Homeland Security Act of 2002, Section 462, transferred responsibilities for the care and placement of unaccompanied children from the Commissioner of the Immigration and Naturalization Service to the Director of the Office of Refugee Resettlement (ORR).

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to authorize a care provider to provide medical, dental, and mental health care services to UAC placed in their facility. Public reporting burden for this collection of information is estimated to average 0.08 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact UACPolicy@acf.hhs.gov.

P-2 | Version 2 Page 1 of 3

Revised MM/DD/YYYY