I have read and understand the above information and consent to the review of information on my child. I understand that updated information on my child may need to be submitted and reviewed again if nursing home placement is sought beyond the certification dates. I also understand that this consent is valid for one year following the date of MRT approval and that a new application must be submitted after that time. Child’s Name (print) Date of Birth Parent/Guardian’s Signature Date ______________________________________________________________________________ Referral Source Name (print) Date ______________________________________________________________________________ Referral Source Signature MEDICAL REVIEW TEAM YOUTH/EMANCIPATED MINOR CONSENT FORM FOR SHORT-TERM POST-HOSPITALIZATION PLACEMENT IN A PEDIATRIC NURSING FACILITY I understand that the attached application constitutes a request for me to stay in a pediatric nursing home for a period not to exceed 30 days per post-hospitalization episode or 90 days in the year following the date of MRT approval. I also understand that the Medical Review Team (MRT), convened by the Massachusetts Department of Public Health, is mandated to certify an individual’s eligibility for short term nursing home placement for individuals under twenty-two (22) years of age. I consent to have the MRT obtain and review my medical, social, developmental and educational records. I understand that all information received by the MRT will be kept confidential. I further understand that the MRT packet will be forwarded only to those facilities or professionals who will be involved in determining my eligibility for a nursing facility.
I have read and understand the above information and consent to the review of information on my child. I understand that updated information on my child may need to be submitted and reviewed again if nursing home placement is sought beyond the certification dates. I also understand that this consent is valid for one year following the date of MRT approval and that a new application must be submitted after that time. Child’s Name (print) Date of Birth Parent/Guardian’s Signature Date ______________________________________________________________________________ Referral Source Name (print) Date ______________________________________________________________________________ Referral Source Signature MEDICAL REVIEW TEAM YOUTH/EMANCIPATED MINOR CONSENT FORM FOR SHORT-TERM POST-HOSPITALIZATION PLACEMENT IN A PEDIATRIC NURSING FACILITY I understand that the attached application constitutes a request for me to stay in a pediatric nursing home for a period not to exceed 30 days per post-hospitalization episode or 90 days in the year following the date of MRT approval. I also understand that the Medical Review Team (MRT), convened by the Massachusetts Department of Public Health, is mandated to certify an individual’s eligibility for short term nursing home placement for individuals under twenty-two (22) years of age. I consent to have the MRT obtain and review my medical, social, developmental and educational records. I understand that all information received by the MRT will be kept confidential. I further understand that the MRT packet will be forwarded only to those facilities or professionals who will be involved in determining my eligibility for a nursing facility.