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Medication Authorization Form For Prescription and Non- ?prescription Medications DSS Division of Licensing Programs Model Form INSTRUCTIONS: Section A

How to fill out medication authorization form

How to fill out a medication authorization form:

1. Start by carefully reading the form's instructions and provisions. Make sure you understand the purpose and requirements of the form.
2. Provide your personal information in the designated sections of the form, such as your full name, address, date of birth, and contact details. Accuracy is crucial to ensure proper identification.
3. Indicate the name, dosage, and frequency of the medication(s) that you are authorizing. Include any specific instructions or restrictions if necessary.
4. If applicable, mention the name and contact information of your healthcare provider who prescribed the medication. This allows the authorized person or entity to verify the authorization if required.
5. Specify the duration of the authorization, whether it is a one-time authorization or ongoing. If there is a time limit, indicate the start and end dates accordingly.
6. Sign and date the form at the appropriate section, ensuring that your signature reflects your legal name as written on the form.
7. If required, have the form witnessed or notarized by a qualified individual. Check the form's instructions or consult local regulations for any specific witnessing or notarization requirements.
8. Make a copy of the completed and signed form for your records before submitting it to the relevant party. Always keep a record of important documents for future reference.

Who needs a medication authorization form?

1. Patients requiring assistance with managing and administering medication may need a medication authorization form. This can include individuals with chronic conditions, disabilities, or those who are temporarily unable to handle medication administration themselves.
2. Caregivers, such as friends, family members, or healthcare professionals, who are responsible for administering medication or handling medication-related tasks on behalf of the patient may also need a medication authorization form.
3. Healthcare facilities, such as hospitals, nursing homes, or assisted living centers, often require a medication authorization form to ensure legal compliance and accountability when administering medication to their patients.

Note: The exact requirement for a medication authorization form may vary depending on the jurisdiction and specific circumstances. It is advisable to consult with healthcare professionals or legal experts for precise guidance in your situation.

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