SFN 395, ICPC Financial & Medical Plan 619-01-30-15

(Revised 4/18/01 ML #2678)

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SFN 395

 

PURPOSE: This plan must be complete and included in the 100A Request. The plan must specify how the child's financial needs will be funded and how medical care will be provided.  Financial and medical arrangements must be discussed with the placement resource, before the child is placed. This will avoid unnecessary hardship on families, as well as delays and disruptions in the placement. This plan will be in effect until proper legal discharge, consistent with the provisions of the Interstate Compact on the Placement of Children.

 

INSTRUCTIONS:

 

Date: Self-explanatory.

 

Child Name: Enter the child's complete name (last, first, middle intial, if any).

 

Date of Birth: Enter the child's date of birth as listed on the child's birth certificate.

 

Legal Status:  

Child(ren) are in Custody/Guardianship of: Enter the name of the legal custodian, i.e. parent, county social service board, Division of Juvenile Services, licensed child placing agency, Department of Human Services, etc.  

 

Address: Enter the full address of the custodian/guardian.

 

Phone: Enter the phone number of the custodian/guardian.

 

Financial Plan (check appropriate boxes):

 

Check the box which describes how the child's financial needs will be met.

 

Medical Plan (check appropriate boxes):

 

Check the box which describes how medical care will be provided.

 

Emergency:

 

Indicate a contact person (and their telephone number) who will give consent for emergency medical treatment, when necessary.  This person should be the custodian or a designated representative of the custodian authorized to give such consent.  

 

Worker Signature: Self-explanatory

 

Supervisor’s Signature: If required by local office policy, enter the signature of the immediate supervisor of the worker.