AB201-ASA1,27,3
1(2) Authorizing a caregiver to consent to health services. (a) A parent may
2authorize a caregiver to consent to health services for the parent's child by
3completing a health services consent form.
AB201-ASA1,27,44 (b) A valid health services consent form shall be all of the following:
AB201-ASA1,27,55 1. In writing.
AB201-ASA1,27,76 2. Dated and signed by the parent and the caregiver whom the parent is
7authorizing to consent to health services for the child.
AB201-ASA1,27,88 3. Voluntarily executed.
AB201-ASA1,27,129 (c) A health services consent form under this section shall remain in effect for
10the period of time specified on the form, which period may not exceed one year from
11the date on which the form is executed, unless the form is revoked or otherwise made
12invalid earlier.
AB201-ASA1,27,1513 (d) Nothing in this section shall be construed to make invalid other instruments
14that are voluntarily executed by a parent authorizing an individual or other entity
15to consent to health services for the parent's child.
AB201-ASA1,27,22 16(3) Effect of health services consent form; form. (a) Unless the health
17services consent form, a guardianship order, or any other court order provides
18otherwise, a caregiver designated in a health services consent form whom a health
19care provider knows is available to consent to health services for a child has priority
20over all other individuals other than a parent who is not currently denied periods of
21physical placement with the child to make health services decisions as provided in
22the health services consent form.
AB201-ASA1,28,623 (b) The department shall prepare the health services consent form and
24accompanying information. The department shall include, in information
25accompanying the form, at least the statutory definitions of the terms used in the

1form. The department shall prepare the form and accompanying information in
2English, Spanish, and other languages spoken by a significant number of state
3residents, as determined by the department. The department shall make the health
4services consent form available at no charge on the Internet. The health services
5consent form prepared by the department shall be in substantially the following
6form:
AB201-ASA1,28,77 HEALTH SERVICES CONSENT
AB201-ASA1,28,11 8Use of form: Use of this form is voluntary, but completion of the form will aid
9the caregiver of a child in ensuring that appropriate and timely health care is
10provided for the child. The form is to be completed by the parent of a child who resides
11with another adult or who is being cared for by another adult.
AB201-ASA1,28,13 12Instructions: If additional space is needed, attach a separate sheet or use
13reverse side of this form.
AB201-ASA1,28,1514 AUTHORIZATION TO CONSENT
15 TO HEALTH SERVICES
AB201-ASA1,28,1916 I, .... (print name of parent), hereby authorize my child's caregiver .... (print
17name of caregiver), who currently resides with or is providing care for (cross out
18"currently resides with or" or "or is providing care for," if inapplicable) my child, ....
19(print name and date of birth of child), to do the following for my child:
AB201-ASA1,28,20 20A. Health Services Consent and Exclusions:
AB201-ASA1,28,2421 Provide consent for emergency and nonemergency health services for my child,
22.... (print name of child), including medical and dental examinations and prescribed
23treatments, including surgery, with the following exceptions: (If there are no
24exceptions, write "none.")
AB201-ASA1,29,1
1........................................................................................................................................
AB201-ASA1,29,22 ........................................................................................................................................
AB201-ASA1,29,43 All health services will be provided under the direction of a licensed dental care
4provider or physician or other licensed health care provider as appropriate.
AB201-ASA1,29,7 5B. Child's Health Care Records. Provide consent to the release of the patient
6health care records of my child, .... (print name of child), with the following
7exceptions: (If there are no exceptions, write "none.")
AB201-ASA1,29,88 ........................................................................................................................................
AB201-ASA1,29,99 ........................................................................................................................................
AB201-ASA1,29,1310 The authority granted under this health services consent form shall remain in
11effect until .... (print date), unless revoked or made invalid earlier. (The parent may
12specify any date agreed to between the parent and caregiver up to one year after the
13date on which the form is signed.)
AB201-ASA1,29,1414 Signature of parent .... Date ....
AB201-ASA1,29,1515 Name of parent (print) ....
AB201-ASA1,29,1616 STATEMENT OF CAREGIVER
AB201-ASA1,29,2217 I understand that .... (name of parent) has authorized me to make health
18services decisions for .... (name of child). I agree to make health services decisions
19for the above-named child consistent with what I and the child's health care
20providers believe is in the child's best interest, consistent with the authority granted
21in this form, and consistent with any other wishes or beliefs of the child's parent of
22which I am aware.
AB201-ASA1,29,2323 Signature of Caregiver .... Date ....
AB201-ASA1,29,2424 CONTACT INFORMATION
AB201-ASA1,29,25 25A. Parent:
AB201-ASA1,30,1
1Name (print) ....
AB201-ASA1,30,22 Home address .... Home telephone number ....
AB201-ASA1,30,33 Work address .... Work telephone number ....
AB201-ASA1,30,44 Other address (specify) .... Other telephone number ....
AB201-ASA1,30,5 5B. Caregiver:
AB201-ASA1,30,66 Name (print) ....
AB201-ASA1,30,77 Home address .... Home telephone number ....
AB201-ASA1,30,88 Work address .... Work telephone number ....
AB201-ASA1,30,99 Other address (specify) .... Other telephone number ....
AB201-ASA1,30,11 10(4) Revocation of health services form. (a) A parent may revoke a health
11services consent form at any time by doing any of the following:
AB201-ASA1,30,1312 1. Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
13the health services consent form.
AB201-ASA1,30,1514 2. Executing a statement, in writing, that is signed and dated by the parent,
15expressing the parent's intent to revoke the health services consent form.
AB201-ASA1,30,1616 3. Executing a subsequent health services consent form.
AB201-ASA1,30,1917 (b) A health services consent form is not valid if the child no longer resides with
18the caregiver or if the caregiver is no longer providing temporary or permanent care
19and supervision for the child.
AB201-ASA1,30,2320 (c) If a caregiver knows that the instrument that authorized him or her to make
21health services decisions for a child has been revoked or is no longer valid, the
22caregiver shall communicate this fact to any health care provider for the child that
23the caregiver knows has a copy of the health services consent form.
AB201-ASA1,31,224 (d) The child's health care provider shall, upon notification of revocation or
25invalidity of the health services consent form, record in the child's medical record the

1time, date, and place of the notification to the health care provider of the revocation
2or invalidity.
AB201-ASA1,31,6 3(5) Duties and immunities. (a) No health care facility or health care provider
4may be charged with a crime, held civilly liable, or charged with unprofessional
5conduct for any of the following in providing health services under a health services
6consent form:
AB201-ASA1,31,107 1. Complying, in the absence of actual knowledge of a revocation, with the
8terms of a health services consent form that is in compliance with this section or the
9decision of a caregiver that is made under a health services consent form that is in
10compliance with this section.
AB201-ASA1,31,1311 2. Acting contrary to or failing to act on a revocation of a health services consent
12form, unless the health care facility or health care provider has actual knowledge of
13the revocation.
AB201-ASA1,31,1714 3. Acting contrary to or failing to act on the health services decision of a parent
15who is not currently denied periods of physical placement with the child, unless the
16health care facility or health care provider has actual knowledge of the parent's
17health services decision.
AB201-ASA1,31,2118 (b) In the absence of actual notice to the contrary, a health care facility or health
19care provider may presume that a parent was authorized to execute the health
20services consent form under the requirements of this section and that the form is
21valid.
AB201-ASA1,31,2422 (c) No caregiver may be charged with a crime or held civilly liable for making
23a decision in good faith under a health services consent form that is in compliance
24with this section.
AB201-ASA1,32,4
1(6) Penalties. (a) Whoever knowingly falsifies or forges a health services
2consent form with intent to create the false impression that a person other than the
3caregiver has been designated to consent to health services for a child is subject to
4a forfeiture not to exceed $200.
AB201-ASA1,32,115 (b) Whoever gives or attempts to give consent for health services based on a
6health services consent form that the individual knows has been executed without
7the voluntary consent of the parent, that the individual knows has been forged or
8substantially altered without the authorization of the child's parent, or that the
9individual knows has been revoked, with the intent to act contrary to the parent's
10wishes may be fined not more than $500 or imprisoned for not more than 30 days or
11both.
AB201-ASA1, s. 38 12Section 38 . 49.155 (5) of the statutes is renumbered 49.155 (5) (a) and
13amended to read:
AB201-ASA1,32,1614 49.155 (5) (a) An individual is liable for the percentage of the cost of the child
15care specified by the department in a printed copayment schedule except as provided
16in pars. (b), (c), and (d)
.
AB201-ASA1,32,21 17(b) An individual who is under the age of 20 and is attending high school or
18participating in a course of study meeting the standards established under s. 115.29
19(4) for the granting of a declaration of equivalency to high school graduation may not
20be determined liable for more than the minimum copayment amount for the type of
21child care received and the number of children receiving child care.
AB201-ASA1, s. 39 22Section 39 . 49.155 (5) (c) and (d) of the statutes are created to read:
AB201-ASA1,32,2523 49.155 (5) (c) An individual who is eligible to receive payments under s. 48.57
24(3m) or (3n) for providing care and maintenance for a child is not liable for a
25copayment for the child.
AB201-ASA1,33,2
1(d) An individual who the department specifies, by rule, is not liable for a
2copayment.
AB201-ASA1, s. 40 3Section 40 . 880.08 (3) (am) (intro.) of the statutes is amended to read:
AB201-ASA1,33,64 880.08 (3) (am) (intro.) When the proposed ward is a minor, notice shall be
5given as provided in s. 879.05 to all of the following persons, if applicable, except that
6notice required to be given by publication shall be published as a class 1 notice
:
AB201-ASA1, s. 41 7Section 41 . Nonstatutory provisions.
AB201-ASA1,33,138 (1) Guardianship and legal custody of children. The joint legislative council
9is requested to study state laws regarding guardianship and legal custody of children
10and the rights and responsibilities of guardians and legal custodians of children. If
11the joint legislative council conducts the study, the joint legislative council shall
12report its findings, conclusions, and recommendations to the legislature in the
13manner provided under section 13.172 (2) of the statutes by January 1, 2005.
AB201-ASA1,33,1914 (2) Kinship care funding management. The department of health and family
15services shall study methods to manage the funding appropriated for kinship care
16payments in order to minimize the need for waiting lists for kinship care payments.
17The department shall submit a report summarizing the results of the study to the
18appropriate standing committees of the legislature in the manner provided under
19section 13.172 (3) of the statutes by June 30, 2004.
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