Form 1 Serious Medical Procedure (SMR) Request Form

OMB Control No: 0970-0561

Expiration date: XX/XX/XXXX

Serious Medical Procedure Request (SMR) Form Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)
Dear Care Provider Program Staff, ORR requires advance approval for the following serious medical/dental procedures1 via the Serious Medical Procedure Request (SMR) Form: Procedures requiring general anesthesia Surgeries Invasive diagnostic procedures (e.g., cardiac catheterization, invasive biopsy, endoscopy, amniocentesis) The SMR form is not needed for procedures that occur during a hospitalization or emergency department visit or that are related to a medical emergency. If it unclear whether a procedure requires ORR approval, please contact ORR’s Division of Health for Unaccompanied Children (DHUC), DCSMedical@acf.hhs.gov.  If ORR approval is needed, care provider program staff must: Complete page 1 and ensure the healthcare provider who is recommending the procedure completes pages 2 and 3 of this form within 2 business days of the recommendation and provide the contact information for the child’s authorized consenter (e.g., parent, legal guardian) Upload the entire form (3 pages) and supporting documentation (e.g., clinical notes) to the UC Portal Health tab. Notify DHUC and the FFS via email that the SMR packet is ready for review. Note: DHUC will not review without all clinical notes.  Facilitate conversations between the healthcare provider and authorized consenter; do not delay submission of this form for consent.   Submit a Treatment Authorization Request (TAR) form through PCU after approval for the procedure is received from DHUC. Note: Procedures may be scheduled in advance of DHUC review but not performed; procedures performed in the absence of approval are subject to non-payment and will become the responsibility of the care provider if the procedure is denied.
Program Information
Program name:							Date submitted:
POC:					Email address:		Phone #:
Child Information
Name:							DOB:
A#:				Country of origin:			ORR Admission date:
Name of authorized consenter for procedure: ______________________________________________________, and
Relationship to child (e.g., mother, potential sponsor, FFS, self): _______________________________
Consent obtained?	Not yet	Yes, date: ____ / ____ / ______
Sponsor’s relationship to child/Release type (e.g., mother, URM program): __________________________________
Sponsor/Release placement city and state: ____________________________________________________________
Referring healthcare provider:			Clinic			City and State		Phone #
Comments/Additional Info

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Serious Medical Procedure Request (SMR) Form Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)
Dear Colleague, The patient for whom you have recommended a procedure is an unaccompanied child in the care of the Department of Health and Human Services (DHHS) Office of Refugee Resettlement (ORR). ORR places children in government-funded care programs to ensure their health and safety until they can be unified with a vetted sponsor. ORR is therefore responsible for the provision of appropriate health care to children while they are in federal care. Serious medical/dental procedures require a higher level of scrutiny and approval, including review by ORR’s Division of Health for Unaccompanied Children (DHUC). The purpose of this form is to collect the information needed to complete this review process. Please complete this form and return it to the care program staff, along with documentation that includes all relevant clinical assessments, indications for the procedure, and anticipated post-operative care needs (e.g., medications, physical/occupational therapy, durable medical equipment, physical/dietary restrictions). Please contact DHUC (DCSMedical@acf.hhs.gov) with questions or concerns. Thank you.
Details of Recommended Procedure(s)
Diagnosis/es:
Diagnosis CPT code(s):
Procedure name(s):
Procedure CPT code(s):
Clinical indications for performing procedure(s):
Potential risks/complications of procedure(s):
From a health perspective, how soon should this procedure occur? ______			wks		months
Potential adverse outcomes or complications if procedure is not done within recommended timeframe:
Proposed date of procedure: _______ / ______ / ________;		TBD, not yet scheduled
Timeframe for follow-up appointment: ­­­­­________ days
Expected number of days after procedure that child will be medically cleared to travel by air/ground: _________
Planned follow-up procedure(s) including diagnosis/procedure codes, risks, timing and potential adverse outcomes:
Points of Contact
Hospital/Clinic:				City/Town:
Clinical Liaison:	Email:			Phone #:
Surgical Admin Liaison:				Phone #:
Hospital Admin Liaison:				Phone #:
Other, specify:				Phone #:

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Comments/Additional Info

Healthcare Provider Signature: ______________________________________________________________

Healthcare Provider Printed Name: ___________________________________________________________

Date: _______ / ______ / __________

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The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 4 minutes per care provider program staff to complete page one and 10 minutes per surgeon to complete pages 2-3, for a total of 14 minutes per program. This estimate includes the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0561 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact UACPolicy@acf.hhs.gov.

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1 ORR does not make approval decisions for abortion services consistent with the stipulated settlement in the Garza litigation. ORR may approve funding when this form is submitted for those services consistent with the current appropriation restriction known as the Hyde Amendment.