AB201,21,2219 (c) A health services consent form under this section shall remain in effect for
20the period of time specified on the form, which period may not exceed one year from
21the date on which the form is executed, unless the form is revoked or otherwise made
22invalid earlier.
AB201,21,2523 (d) Nothing in this section shall be construed to make invalid other instruments
24that are voluntarily executed by a parent authorizing an individual or other entity
25to consent to health services for the parent's child.
AB201,22,6
1(3) Effect of health services consent form; form. (a) Unless the health
2services consent form, a guardianship order, or any other court order provides
3otherwise, a caregiver designated in a health services consent form who is known to
4a health care provider to be available to consent to health services for a child has
5priority over all other individuals other than a parent to make health services
6decisions as provided in the health services consent form.
AB201,22,157 (b) The department shall prepare the health services consent form and
8accompanying information. The department shall include, in information
9accompanying the form, at least the statutory definitions of the terms used in the
10form. The department shall prepare the form and accompanying information in
11English, Spanish, and other languages spoken by a significant number of state
12residents, as determined by the department. The department shall make the health
13services consent form available at no charge on the Internet. The health services
14consent form prepared by the department shall be in substantially the following
15form:
AB201,22,1616 HEALTH SERVICES CONSENT
AB201,22,20 17Use of form: Use of this form is voluntary, but completion of the form will aid
18the caregiver of a child in ensuring that appropriate and timely health care is
19provided for the child. The form is to be completed by the parent of a child who is
20being cared for by another adult.
AB201,22,22 21Instructions: If additional space is needed, attach a separate sheet or use
22reverse side of this form.
AB201,23,2
1AUTHORIZATION TO CONSENT
2 TO HEALTH SERVICES
AB201,23,53 I, .... (print name of parent), hereby authorize my child's caregiver .... (print
4name of caregiver), to do the following for my child, .... (print name and date of birth
5of child):
AB201,23,6 6A. Routine Health Services Consent and Exclusions:
AB201,23,107 Provide consent for routine health services for the above-named child,
8including medical and dental examinations and nonemergency prescribed
9treatments (for example, tooth repair, immunizations, and medications), with the
10following exceptions: (If there are no exceptions, write "none.")
AB201,23,1111 ........................................................................................................................................
AB201,23,1212 ........................................................................................................................................
AB201,23,13 13B. Emergency Health Services Consent and Exclusions:
AB201,23,1514 In case of a medical emergency involving the above-named child, arrange for
15emergency health services using the following procedures:
AB201,23,1716 1. A reasonable effort will be made to contact me and secure my consent for
17needed emergency health services, including surgical procedures.
AB201,23,1918 2. If I cannot be located within a reasonable time, the child's caregiver has the
19authority to consent to emergency health services, including surgery performed.
AB201,23,2120 3. All health services will be provided under the direction of a licensed dental
21care provider or physician or other licensed health care provider as appropriate.
AB201,24,3
1I have no objections to the caregiver exercising his or her authority to consent
2to emergency health services as provided above, with the following exceptions: (If
3there are no exceptions, write "none.")
AB201,24,44 ........................................................................................................................................
AB201,24,55 ........................................................................................................................................
AB201,24,96 The authority granted under this health services consent form shall remain in
7effect until .... (print date), unless revoked or made invalid earlier. (The parent may
8specify any date agreed to between the parent and caregiver up to one year after the
9date on which the form is signed.)
AB201,24,1010 Signature of parent .... Date ....
AB201,24,1111 Name of parent (print) ....
AB201,24,1212 STATEMENT OF CAREGIVER
AB201,24,1813 I understand that .... (name of parent) has authorized me to make health
14services decisions for .... (name of child). I agree to make health services decisions
15for the above-named child consistent with what I and the child's health care
16providers believe is in the child's best interest, consistent with the authority granted
17in this form, and consistent with any other wishes or beliefs of the child's parent of
18which I am aware.
AB201,24,1919 Signature of Caregiver .... Date ....
AB201,24,2020 CONTACT INFORMATION
AB201,24,21 21A. Parent:
AB201,24,2222 Name (print) ....
AB201,24,2323 Home address .... Home telephone number ....
AB201,24,2424 Work address .... Work telephone number ....
AB201,24,2525 Other address (specify) .... Other telephone number ....
AB201,25,1
1B. Caregiver:
AB201,25,22 Name (print) ....
AB201,25,33 Home address .... Home telephone number ....
AB201,25,44 Work address .... Work telephone number ....
AB201,25,55 Other address (specify) .... Other telephone number ....
AB201,25,7 6(4) Revocation of health services form. (a) A parent may revoke a health
7services consent form at any time by doing any of the following:
AB201,25,98 1. Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
9the health services consent form.
AB201,25,1110 2. Executing a statement, in writing, that is signed and dated by the parent,
11expressing the parent's intent to revoke the health services consent form.
AB201,25,1212 3. Executing a subsequent health services consent form.
AB201,25,1413 (b) A health services consent form is not valid if the minor no longer resides
14with the caregiver.
AB201,25,1815 (c) If a caregiver knows that the instrument that authorized him or her to make
16health services decisions for a child has been revoked or is no longer valid, the
17caregiver shall communicate this fact to any health care provider for the child that
18the caregiver knows has a copy of the health services consent form.
AB201,25,2219 (d) The child's health care provider shall, upon notification of revocation or
20invalidity of the health services consent form, record in the child's medical record the
21time, date, and place of the notification to the health care provider of the revocation
22or invalidity.
AB201,26,2 23(5) Duties and immunities. (a) No health care facility or health care provider
24may be charged with a crime, held civilly liable, or charged with unprofessional

1conduct for any of the following in providing health services under a health services
2consent form:
AB201,26,63 1. Complying, in the absence of actual knowledge of a revocation, with the
4terms of a health services consent form that is in compliance with this section or the
5decision of a caregiver that is made under a health services consent form that is in
6compliance with this section.
AB201,26,97 2. Acting contrary to or failing to act on a revocation of a health services consent
8form, unless the health care facility or health care provider has actual knowledge of
9the revocation.
AB201,26,1210 3. Acting contrary to or failing to act on the health services decision of a parent,
11unless the health care facility or health care provider has actual knowledge of the
12parent's health services decision.
AB201,26,1613 (b) In the absence of actual notice to the contrary, a health care facility or health
14care provider may presume that a parent was authorized to execute the health
15services consent form under the requirements of this section and that the form is
16valid.
AB201,26,1917 (c) No caregiver may be charged with a crime or held civilly liable for making
18a decision in good faith under a health services consent form that is in compliance
19with this section.
AB201,26,23 20(6) Penalties. (a) Whoever knowingly falsifies or forges a health services
21consent form with intent to create the false impression that a person other than the
22caregiver has been designated to consent to health services for a child is subject to
23a forfeiture not to exceed $200.
AB201,27,524 (b) Whoever gives or attempts to give consent for health services based on a
25health services consent form that the individual knows has been executed without

1the voluntary consent of the parent, that the individual knows has been forged or
2substantially altered without the authorization of the child's parent, or that the
3individual knows has been revoked, with the intent to act contrary to the parent's
4wishes may be fined not more than $500 or imprisoned for not more than 30 days or
5both.
Note: Section 29 creates a new section in the Children's Code that allows a parent
to complete a form that gives an adult with whom a child lives the authority to make
health services decisions for the child on behalf of the parent.
This Section includes a health services consent form. The form must be signed by
the parent and by the caregiver. DHFS must prepare the health services consent form
and accompanying information and make the form available, at no charge, on the
Internet. The form must be prepared in English, Spanish, and any other language that
DHFS determines is spoken by a significant number of state residents.
A valid health services consent form gives the caregiver the authority to make
routine and emergency health care decisions for the named child. A contravening
decision by a parent, however, supersedes the caregiver's decision.
This Section allows a parent to revoke a health services consent form. Also, a form
is not valid if the child no longer lives with the caregiver.
This Section provides immunity from liability for health care providers who act in
good faith in complying with a health services consent form. In addition, a caregiver may
not be liable for making a decision in good faith under a valid health services consent
form.
The Section provides penalties for falsifying a health services consent form and
for attempting to give consent under a forged or revoked form with the intent of acting
contrary to the wishes of the child's parent's.
AB201, s. 30 6Section 30 . 49.155 (5) of the statutes is renumbered 49.155 (5) (a) and
7amended to read:
AB201,27,108 49.155 (5) (a) An individual is liable for the percentage of the cost of the child
9care specified by the department in a printed copayment schedule except as provided
10in pars. (b), (c), and (d)
.
AB201,27,15 11(b) An individual who is under the age of 20 and is attending high school or
12participating in a course of study meeting the standards established under s. 115.29
13(4) for the granting of a declaration of equivalency to high school graduation may not
14be determined liable for more than the minimum copayment amount for the type of
15child care received and the number of children receiving child care.
AB201, s. 31
1Section 31 . 49.155 (5) (c) and (d) of the statutes are created to read:
AB201,28,42 49.155 (5) (c) An individual who is receiving payments under s. 48.57 (3m) or
3(3n) for providing care and maintenance for a child is not liable for a copayment for
4the child.
AB201,28,65 (d) An individual who the department specifies, by rule, is not liable for a
6copayment.
Note: Sections 30 and 31 create an exception to the requirement that an
individual who receives a child care subsidy is liable for a percentage of the cost of the
child care. Under Section 31, a kinship care relative and a person who the department
of workforce development specifies is not liable for a copayment are not liable for a
copayment.
AB201, s. 32 7Section 32 . 880.08 (3) (am) (intro.) of the statutes is amended to read:
AB201,28,108 880.08 (3) (am) (intro.) When the proposed ward is a minor, notice shall be
9given as provided in s. 879.05 to all of the following persons, if applicable, except that
10notice required to be given by publication shall be published as a class 1 notice
:
Note: Section 32 modifies current law so that notice of a hearing to appoint a
guardian for a minor must be published in a newspaper as a class 1 notice (i.e., published
once) if personal service is not possible. Under current law, such notice must be published
as a class 3 notice (i.e., published 3 times).
AB201, s. 33 11Section 33 . Nonstatutory provisions.
AB201,28,1712 (1) Guardianship and legal custody of minors. The joint legislative council
13is requested to study state laws regarding guardianship and legal custody of minors
14and the rights and responsibilities of guardians and legal custodians. If the joint
15legislative council conducts the study, the joint legislative council shall report its
16findings, conclusions, and recommendations to the legislature in the manner
17provided under section 13.172 (2) of the statutes by January 1, 2005.
AB201,29,218 (2) The department of health and family services shall study methods to
19manage funding for kinship care payments in order to minimize the need for waiting
20lists for kinship care payments. The department shall submit a report summarizing

1the results of the study to the appropriate standing committees of the legislature in
2the manner provided under section 13.172 (3) of the statutes by June 30, 2004.
Note: Section 33 requests the Joint Legislative Council to study state laws
regarding guardianship and legal custody of minors and the rights and responsibilities
of guardians and legal custodians.
Section 33 also requires DHFS to study methods to manage funding for kinship
care payments in order to minimize the need for waiting lists for payments and to report
on the results of its study to the appropriate standing committees of the legislature by
June 30, 2004.
AB201,29,33 (End)
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