CMS-07-021/023 - Los Angeles County Department of Children and ...

) DCFS 4158, signed by the CSW if the parent/legal guardian is unavailable or
unwilling to sign the DCFS 179; and
c) Blank DCFS 561(a), 561(b) and 561(c).
EXHIBIT I
d) Retain photocopies in the Psychological/Medical/ Dental/School Records folder.
5. Review and explain how to use the DCFS 561(a), (b), (c) with the caregiver.
6. Document the date the HEP Binder and required forms and documents were given
to and reviewed with the caregiver in the Contact Notebook.
7. Mail the DCFS 1726 to the school the child attended prior to his or her detention.
Place a copy in the Psychological/Medical/Dental/School Records folder.
8. Ensure that the following information is entered in CWS/CMS. You may ask the
Public Health Nurse (PHN) or the designated person for assistance.
a) The name, address, and telephone number of the child’s doctor and dentist;
b) The child’s immunization history;
c) Any allergies and current or chronic health conditions;
d) The name, address and phone number of the school the child last attended; and
e) Significant family medical problems, if any.
9. Generate an initial HEP after data have been entered into CWS/CMS. Mail or give a
copy to the caregiver for inclusion in the HEP Binder.
10. Instruct the caregiver to take the DCFS 561(a), (b) or (c) to all medical, dental or
psychological appointments and to ask the health care provider to document
information about the appointment and to authenticate with signature and/or
signature stamp.
11. Instruct the caregiver to take the HEP to all educational appointments and to ask the
education provider to add information about the appointment on the HEP document.
PG 0080-505.20 (Rev 010/06) Page 7 of 12