TX HHS Form 4205. Consent by Foster Parents or Medical Consenters for Health Passport

Form 4205 is a Texas Early Childhood Intervention (ECI) document used to record a foster parent’s or medical consenter’s consent (or refusal) to include certain ECI records in the Texas Health Passport system. This form plays a key role in how health and developmental information about a child in foster care is shared among authorized providers while ensuring confidentiality and compliance with state and federal law.

Purpose of the Form

The primary purpose of Form 4205 is to document whether a foster parent, medical consenter, or surrogate parent agrees to the release of specific ECI-related records into the Health Passport. The Health Passport is an electronic health information system created by the Texas Health and Human Services Commission (HHSC) to give health care providers and authorized decision-makers access to essential medical information while a child is in foster care.

Who Must Complete This Form

This form is completed by an individual who is legally authorized to consent to medical care for a child in foster care, such as:

• A foster parent
• A medical consenter appointed by the court or DFPS
• A surrogate parent under federal special education law

The child must be under the conservatorship of the Texas Department of Family and Protective Services (DFPS) and enrolled or eligible for ECI services.

When Form 4205 Is Required

Form 4205 is used when ECI records may be shared through the Health Passport system. It is typically requested during or shortly after a child begins receiving ECI services, or when updates to service plans or records may be added to the Health Passport.

The form is not required if the authorized individual chooses not to consent to any release of information. Refusal to sign does not affect the child’s eligibility for ECI services.

Legal and Regulatory Background

The Health Passport system and this consent form are governed by several legal authorities, including:

• Texas Family Code Sections 266.006 and 266.007
• Texas Administrative Code, 1 TAC Section 354.1186
• Individuals with Disabilities Education Act (IDEA)
• 34 Code of Federal Regulations (CFR) Sections 303.401, 303.402, and 303.27

These laws require secure handling of foster children’s health information and define who may access and consent to the sharing of such records.

Explanation of Key Sections of the Form

Authorized Consenter Information

This section identifies the foster parent or medical consenter and confirms their legal authority to act on behalf of the child for medical and ECI-related decisions.

Consent Statement

The form explains the purpose of the Health Passport and asks whether the consenter agrees to share ECI records, including information from the child’s Individualized Family Service Plan (IFSP).

Record Selection

The consenter must mark which records may be released. Options include allowing release of IFSP service pages, additional specified information, or refusing consent entirely.

Voluntary Nature of Consent

This section clarifies that consent is voluntary, may be withdrawn at any time, and expires one year from the date of signature for new releases.

Signature and Date

The form must be signed and dated by the authorized individual. An ECI staff member also records their initials to confirm proper completion.

Documents Commonly Attached or Referenced

• Individualized Family Service Plan (IFSP) service pages
• Additional written descriptions of records to be shared
• Copies of relevant Texas Family Code sections (often provided for review)

Practical Tips for Completing Form 4205

• Review the IFSP carefully before consenting to release any information.
• Only check boxes for records you fully understand and agree to share.
• Keep a copy of the signed form for your records.
• Confirm that the date and signatures are complete to avoid processing delays.

Common Mistakes to Avoid

• Signing without understanding which records will be shared
• Forgetting to mark any consent option
• Missing the signature date
• Assuming consent is permanent rather than time-limited

Real-Life Examples of When This Form Is Used

• A foster parent agrees to share ECI service records so a new pediatric specialist can review the child’s developmental history.
• A medical consenter limits information sharing to specific IFSP pages only.
• A surrogate parent declines consent while still allowing the child to receive all ECI services.

Frequently Asked Questions

Does refusing to sign Form 4205 affect ECI services?

No. A child’s right to receive ECI services is not affected by refusal to consent.

Who can access information in the Health Passport?

Authorized health care providers and individuals permitted under Texas law may access the information.

Can consent be withdrawn later?

Yes. Consent may be withdrawn at any time, except for actions already taken.

How long does the consent remain valid?

Consent for new releases expires one year from the date it is signed.

Is the Health Passport secure?

Yes. The system must meet HIPAA privacy and security requirements.

Micro-FAQ

• Purpose: Allows or denies sharing ECI records in the Health Passport.
• Who files: Foster parent, medical consenter, or surrogate parent.
• Deadline: As requested during ECI service coordination.
• Attachments: IFSP service pages or other specified records.
• Submitted to: ECI program and HHSC-related systems.

Related Forms and Resources

• ECI Individualized Family Service Plan (IFSP) forms
• DFPS medical consent documentation
• Other Texas foster care health forms

Form Details

Form name: Consent by Foster Parent or Medical Consenter for Health Passport

Form number: Form 4205

Program: Texas Early Childhood Intervention (ECI)

Region: Texas

Revision date: November 2020