Tools and Medical Forms For Children with Special Needs, Cincinnati Children's Hospital Medical Center

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Tools and Medical Forms for Children With Special Needs

General Medical | Emergency Medical | Additional Resources

General Medical Forms

To assist physicians and caregivers of children with specialized health care needs, the staff of the Center for Infants and Children with Special Needs at Cincinnati Children's Hospital Medical Center provides the forms below.

You can download the forms below in portable document format (.pdf). You must have Adobe Acrobat" Reader installed on your computer to read pdf files.

All About Me Form
Authorization for Use and / or Disclosure of Protected Health Information
Authorization for Use and / or Disclosure of Protected Health Information to Schools
Chronic Care Visit Form
Discharge Planning Form
Parent Notebook, developed by the Center for Infants and Children with Special Needs at Cincinnati Children's, can help you organize important health care and support information.
American Academy of Pediatrics provides samples of different types of caregiver notebooks.
Social Assessment Form
Transition Checklist

In addition, The National Initiative for Children's Healthcare Quality (NICHQ), sponsored by the American Academy of Pediatrics (AAP), provides an online toolkit for parents and primary care practioners for use in the assessment and treatment of ADHD.

The information you provide will assist us in assessing your child's needs.

These forms are not to be used for self-diagnosis and are best used in conjunction with a health care provider.

Emergency Medical Forms

In preparation for a medical emergency, it is recommended that the following completed forms be provided to the utility and Emergency Medical Service (EMS) companies providing services to the family.

EMS Medical Emergency Form / Letter
Utility Medical Emergency Form / Letter
EMS Emergency Information Form for Children with Special Needs, developed by the American College of Emergency Physicians and the American Academy of Pediatrics
Family Readiness Kit, developed by the American Academy of Pediatrics, provides information on how to prepare for a disaster.

Additional Resources

Care of the Child With a Tracheostomy developed by the Center for Infants and Children with Special Needs at Cincinnati Children's
Bureau for Children with Medical Handicaps (BCMH) application form can be downloaded.
Request for Medicaid Home and Community-Based Services application can be used to apply for any Ohio Waiver or Home Health Care program. However, you must receive Medicaid to be eligible for waiver services.