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

OMB 0970-0554 [Valid through 02/28/2021]
U.S. Department of Health and Human Services

Office of Refugee Resettlement
Authorization for Medical, Dental, and Mental Health Care, Rev. 11/01/2011

OFFICE OF REFUGEE RESETTLEMENT
Division of Children’s Services
AUTHORIZATION FOR MEDICAL, DENTAL, AND MENTAL HEALTH CARE
The Department of Health and Human Service (HHS), Office of Refugee Resettlement (ORR), Division
of Children’s Services (DCS) is responsible for coordinating and implementing the care and custody of
the following minor pursuant to section 462 of the Homeland Security Act of 2002 (6 U.S.C. §279):
Minor's Name:

Alien Number:

Date of Birth:

Nationality:

ORR hereby Authorizes , hereinafter “care provider,” to arrange medical, dental, and mental
health care for said minor under the following terms and conditions:
care provider :

Abbott House Shelter

1. Licensing and Reimbursement
•All medical, dental, or mental health services for the minor will be by a State licensed provider.
•The licensed medical, dental, or mental health provider must be willing to accept the Medicare
reimbursement rate, payment on a fee for service basis, or to provide services for no fee.
2. Authorization and Notification
•The care provider shall secure authorization from ORR before consenting to any non-emergency
medical, dental or medical health services; except for initial medical screening.
•The care provider shall consent to the provision of emergency treatment recommended by a
licensed medical, dental, or mental health provider. The care provider shall notify ORR of the
emergency immediately following treatment if possible, or within 24 hours after the initial incident.
•Significant surgical or medical procedures require heightened ORR involvement. Please refer to
ORR instructions and procedures on medical services requiring heightened ORR involvement in
these special cases.
•Minors have the right to be tested for HIV or other sexually transmitted diseases; the care provider
shall ensure the minor receives the test(s) as requested.
•The care provider is authorized to dispense over-the-counter medications and prescription
medications to minors in care following appropriate directions for use as outlined by the prescribing
physician, or in the case of over-the-counter medications, following the manufacturer’s directions.

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 0.02 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 [email protected].

Authorization for Medical, Dental, and Mental Health Care, Rev. 11/01/2011
ORR UAC/P-2

U.S. Department of Health and Human Services

Office of Refugee Resettlement
Authorization for Medical, Dental, and Mental Health Care, Rev. 11/01/2011

3. Medical and Dental Exams/Screenings
•Minors in care shall receive a medical exam within 48 hours of placement in a care provider
program, unless the minor obtained a medical exam within one calendar year and while under the
care of another ORR-funded care provider.
•Minors in care shall also receive an initial dental examination within 90 days of placement, but
no sooner than their 30th day in the custody of ORR.
4. Immunizations
•The care provider shall ensure that all minors in care receive necessary immunizations.
•Females 10 years or older must undergo a quantitative blood pregnancy test, with the minor’s
consent, before being administered any immunization.
5. Medical, Dental, and Mental Health Records/Confidentiality
•Care providers shall (1) obtain copies of all screenings, exams, or testing performed on a minor in
care, signed by the licensed health care professional, (2) provide copies to ORR, when requested,
and (3) ensure that medical records are maintained in the minor’s file.
•All records maintained by the care provider in reference to the minor’s health care are the property
of ORR. Care providers may not release health information about the minor to any individual or
organization without prior express authorization of ORR, except in the following instances: to the
minor’s educational program or medical, mental health, dental, and other service providers to the
extent that the information is needed for the minor’s education, recreation, social development,
medical, dental, or mental health treatment. The care provider must give ORR and its designees, as
directed by ORR, unrestricted access to information about the minor at all times.

__________________________________________
Signature - Authorized Representative of Care Provider

__
Date

________________
Telephone Number

__________________________________________
Signature - Official Representative
Office of Refugee Resettlement
Administration for Children and Families
US Department of Health and Human Services

_________
Date

________________
Telephone Number

Authorization for Medical, Dental, and Mental Health Care, Rev. 11/01/2011
ORR UAC/P-2