Hennepin County Maternal Child Health – Affidavit of Court Order


Minnesota CarePartner
393 N Dunlap St. #300  St. Paul, MN 55104
P: 612-289-5656   F: 651-925-0278

Hennepin County Public Health - Maternal Health Unit
Affidavit of Presence of Court Order

 

Referent Name:    
Referent eMail:    
Client Name:    
Client Date of Birth:     

As an agent of Hennepin County Public Health, acting on behalf of the individual named above (client), I attest to the following:

  • A court order has been signed by a judge in a court of competent jurisdiction authorizing this agency to act on behalf of the above named individual.
  • This court order authorizes this agency and, by extension, me to consent to mental health services on the client's behalf.
  • A copy of this court order has been provided to Minnesota CarePartner.
  • I will notify Minnesota CarePartner in the event any such court order is rescinded or revoked.

My signature below indicates my acknowledgement of and attestation to the statements contained in this affidavit.

Leave this empty:

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Signature Certificate
Document name: Hennepin County Maternal Child Health – Affidavit of Court Order
lock iconUnique Document ID: c84a10232e1f8eca8dcdd3d9e50d4ffbc1c9e61f
Timestamp Audit
November 20, 2020 8:06 am CSTHennepin County Maternal Child Health – Affidavit of Court Order Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 101.50.105.23, 127.0.0.1, 198.71.237.35, 0.0.0.0
November 20, 2020 8:22 am CST Document owner justinscharr@mncarepartner.com has handed over this document to rootsforms@mncarepartner.com 2020-11-20 08:22:09 - 71.34.7.204
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November 20, 2020 8:45 am CSTMNCP Intake - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 71.34.7.204
November 20, 2020 8:46 am CSTMNCP Intake - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 71.34.7.204
November 20, 2020 8:47 am CSTMNCP Intake - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 71.34.7.204