New Hampshire's Division for Children, Youth and Families uses this two-sided statement to verify the health of foster and adoptive family applicants and the people in their household. The individual lists their illness history and authorizes release; the provider then records significant health history, immunizations and an impression of whether the person is free of impairments that could affect children's care.
Only a currently licensed physician, physician assistant or APRN may complete and sign the provider side, checking their profession. The individual or legal representative completes the illness history and signs the release on the front, which lasts two years.
Download the current version from the source each time; forms change without notice.
Medical Information Statement
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Only currently licensed physicians, physician assistants and APRNs. The provider side lists those three professions and asks the signer to check the matching box before completing the health history, immunization and impression sections, then sign with printed name and date.
For adult household members and caregivers, dates of pertussis (whooping cough) and annual influenza vaccination, or the date of illness. For children, a copy of the current immunization record must be attached and the provider states whether the child is up to date per AAP, ACIP and AAFP.
The release on the individual's side ends two years from the date it is signed, or earlier if the person asks. They can stop their permission at any time by writing a note to DHHS.