- 4205-S.pdf (116.56 KB)
- 4205-S_instruct.pdf (12.48 KB)
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
- Read the statements on Pages 1, 2, and 3.
- Place an X in the appropriate box or boxes on Page 1.
- 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