LAC 67:V.1135. Physician Notification

A. The Department of Children and Family Services establishes procedures for implementation of the physician notification, as required by R.S. 40:1086.11. 1. A physician identifying a newborn exhibiting symptoms of withdrawal or other observable and harmful effects in his physical appearance or functioning due to the use of a controlled dangerous substance, as defined by R.S. 40:961 et seq., in a lawfully prescribed manner by the mother during pregnancy shall use the DCFS form, physician notification of substance exposed newborns; no prenatal neglect suspected, to comply with the requirements of the Comprehensive Addiction and Recovery Act. The following form, which may be obtained from the DCFS website at www.dcfs.la.gov/, shall be used to notify DCFS. Physician Notification of Substance Exposed Newborns No Prenatal Neglect Suspected LA DCFS: This notification does not constitute a report of child abuse and or neglect and shall be faxed to Centralized Intake at (225) 342-7768. This notification is used to notify DCFS newborns who exhibit symptoms of withdrawal or other observable and harmful effects in his physical appearance or functioning that a physician believes is due to the use of a controlled dangerous substance, as defined by R.S. 40:961 et seq., in a lawfully prescribed manner, by the mother during pregnancy. If a newborn is exhibiting withdrawal symptoms that are believed to be the result of unlawful use of a controlled dangerous substance; or, if you suspect abuse and or neglect including suspicion of prenatal neglect, you must contact the CPS Hotline at 1-855-4LA-KIDS to make a report of suspected child abuse/neglect. Newborn’s Information Last Name: __________________________________ First Name:____________________________________________ Date of Birth: __ __ / __ __ / __ __ __ __ Gender: ☐ Male ☐ Female Race: ☐ White ☐ African American ☐ Asian/Pacific Islander ☐ Hispanic/Latino ☐ Other Substances newborn was exposed to, if known: ☐ Amphetamines ☐ Barbiturates ☐ Opioids ☐ Opioid Agonist ☐ Benzodiazepines ☐ Other (List) ____________________________________ Was there a Neonatal Abstinence Syndrome screening completed? ☐ Yes ☐ No Mother’s Information Last Name: ___________________________________ First Name:____________________________________________ Date of Birth: __ __ / __ __ / __ __ __ __ Race: ☐ White ☐ African American ☐ Asian/Pacific Islander ☐ Hispanic/Latino ☐Other Marital Status: ☐ Single ☐ Married ☐ Separated ☐ Divorced ☐ Other ☐ Unknown Address upon discharge: ________________________City: ____________________ State: ______ Zip Code: ________ Provider Information Name of Hospital: _______________________________________________ Notification Date: __ __/ __ __/ __ __ __ __ Physician’s Name: _____________________________________________________________ Address: ______________________________________City: _____________________ State: _____ Zip Code: ________ Other individuals who provided input for this notification (Name and Title):______________________________________ Pertinent Discharge Referral(s) and Education Referral(s), as applicable: ☐ Pediatrician ☐ Pediatric Specialist ☐ OB/GYN ☐ PCP ☐ Early Steps ☐ Medicaid ☐ Substance Use Disorder Assessment/Treatment ☐ Behavioral/Mental Health Services ☐ Housing ☐ Office of Public Health ☐ Other Referrals: ______________________________________________________________ ___________________________________________________________________________________________________ Educational materials provided: ☐ Car Safety Seats ☐ Shaken Baby Syndrome ☐ Safe Sleep ☐ Early Steps ☐ Other Educational materials provided: (Specify) ________________________________________________________ __________________________________________________________________________________________________ Additional comments regarding the needs of the newborn and family: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 2. The physician will complete the form with the following required information: a. identifying information about the newborn; b. substance to which the newborn was exposed; c. identifying information about the mother; d. identification of the physician who is providing the notification; and e. plan of care for newborn and mother including a listing of educational materials provided, referrals made, additional discharge instructions, and information gained from the mother regarding care of the newborn. 3. The notifying physician shall transmit the form via fax to DCFS at (225) 342-7768. B. DCFS shall monitor plans of care via the regional child welfare teams with multidisciplinary professionals to address the availability and delivery of the appropriate services for the newborn, affected caregiver and family. C. DCFS shall maintain information on plans of care for the sole purpose of non-identifying data reporting as required by 42 USC 5106a(d). Information will be maintained for 24 months from the date of the notification to DCFS.