Form 4205, Consent by Foster Parents or Medical Consenters for Health Passport

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Effective Date: 11/2020




Form 4205 is used by a foster parent or medical consenter of a child in the ECI program to consent to the release of the child’s IFSP or other medical information to the Health Passport system.

Copies and Distribution

Foster Parent or Surrogate Parent

Child's file


Five years

Detailed Instructions

  1. Read the statements on Pages 1, 2, and 3.
  2. Place an X in the appropriate box or boxes on Page 1.
  3. Sign and date the form on Page 1.

Acronyms and Definitions

Health Passport: An electronic health information system created by HHSC, under the direction of Texas Family Code, Section 266.006. Its purpose is to ensure that children and their health care providers and medical consenters have access to their health-related information while the child is in foster care.

IFSP: Individual Family Services Plan

Medical consenter: Documented as medical consenter by the Department of Family and Protective Services