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5.3.3 Good Cause Claim The Good Cause Claim form (DCF-F-DWSP 2019) must be provided to any health care applicant or member who requests one. It describes the circumstances that support a claim and how to document a claim. The parent or caretaker must sign and date the Good Cause Claim form in order to initiate the claim. The IM agency must send a copy of the submitted Good Cause Claim form to the parent or caretaker upon request. The child support agency (CSA) must be informed within two business days that a good cause claim has been filed. When the CSA is informed of a claim, they will immediately suspend all activities to establish paternity or secure medical support until notified of the final determination. 5.3.4 Circumstances The IM agency must determine whether or not cooperation is against the best interests of the child. Cooperation is waived only if one of the following is true: • The parent or caretaker’s cooperation is reasonably anticipated to result in physical or emotional harm to one of the following: ◦ Child. This means that the child is so emotionally impaired, that their normal functioning is substantially affected. ◦ Parent or Caretaker. This means the impairment is of such a nature or degree that it reduces that person's capacity to adequately care for the child. • At least one of the following circumstances exists, and it is reasonably anticipated that proceeding to establish paternity or secure support or both would be detrimental to the child: ◦ The child was conceived as a result of incest or sexual assault. ◦ A petition for the child's adoption has been filed with a court. ◦ The parent or caretaker is being assisted by a public or private social agency in deciding whether or not to terminate parental rights and this has not gone on for more than three months. 5.3.5 Evidence An initial good cause claim may be based only on evidence in existence at the time of the claim. There is no limit to the age of the evidence. Once a final determination is made, including any fair hearing decision, any subsequent claim must be based on new evidence. The following may be used as evidence: • Birth certificates or medical or law enforcement records that indicate that the child may have been conceived as a result of incest or sexual assault. • Court documents or other records that indicate that a petition for the adoption of the child has been filed with a court. • Court, medical, criminal, child protective services, social services, psychological school, or law enforcement records that indicate the alleged father or absent parent might inflict physical or emotional harm on the member or the child.