Get the free Glucagon Authorization Form - Canyons School District

Utah Department of Health/Utah State Office of Education Glucagon Authorization Form In accordance with Utah Code 53A11604 Student Name: Date of Birth: Name of School: Name of School District: Health

How to fill out glucagon authorization form

How to fill out a glucagon authorization form:

1. Start by providing your personal information: Fill out your full name, address, phone number, and any other required contact information. Make sure to double-check for accuracy.
2. Next, indicate the reason for needing the glucagon authorization form: Specify whether it is for yourself or for someone else, such as a child, family member, or student. This will help ensure the proper administration of glucagon if necessary.
3. If the form requires your healthcare provider's information, include their name, contact details, and any relevant medical practice information. This information may be used to verify the validity of the glucagon authorization form.
4. Proceed to fill in the section requesting medical details: Provide any pertinent medical history, such as allergies, medical conditions, and current medications. This information is crucial for healthcare providers to understand your specific needs and potential risks.
5. If applicable, include the name and contact information of any emergency contacts who should be notified in case of a severe hypoglycemic event. This is important to ensure that prompt assistance can be obtained if glucagon is administered.
6. Carefully read and acknowledge any terms and conditions stated on the form. This may include legal disclaimers, consent for treatment, or compliance with any applicable laws or regulations. Be sure to understand and agree to these terms before signing the authorization form.
7. Sign and date the glucagon authorization form, indicating your consent and understanding of the information provided.

Who needs a glucagon authorization form?

1. Individuals with diabetes: People with diabetes may require a glucagon authorization form to ensure that this potentially life-saving medication can be administered promptly in case of severe hypoglycemia when they are unable to self-administer.
2. Parents or guardians of children with diabetes: If a child with diabetes is under the care of a school, childcare provider, or any other institution, parents or guardians may be required to fill out a glucagon authorization form. This allows the authorized individuals to administer glucagon if the child experiences severe hypoglycemia.
3. Healthcare professionals or first responders: Medical professionals, such as nurses, doctors, emergency medical technicians, and school nurses, may need a glucagon authorization form to be authorized to administer the medication in emergency situations. This ensures that they can effectively provide the necessary treatment to individuals experiencing severe hypoglycemia, even without immediate access to their personal medical records.

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What is glucagon authorization form?

Glucagon authorization form is a document that allows certain individuals to administer glucagon in case of emergency situations such as severe hypoglycemia.

Who is required to file glucagon authorization form?

Individuals who have diabetes and may require emergency glucagon administration, as well as their caregivers or school personnel, are required to file the glucagon authorization form.

How to fill out glucagon authorization form?

To fill out the glucagon authorization form, one must provide personal information, emergency contact details, physician's information, and follow the instructions provided on the form.

What is the purpose of glucagon authorization form?

The purpose of the glucagon authorization form is to ensure that individuals with diabetes have access to emergency glucagon administration in case of severe hypoglycemia when they are unable to administer it themselves.

What information must be reported on glucagon authorization form?

The glucagon authorization form must include personal information, emergency contact details, physician's information, healthcare provider's instructions for glucagon administration, and consent signatures.

When is the deadline to file glucagon authorization form in 2023?

The deadline to file the glucagon authorization form in 2023 is typically before the start of the school year or as required by the healthcare provider.

What is the penalty for the late filing of glucagon authorization form?

The penalty for the late filing of the glucagon authorization form may result in delays in emergency treatment or restrictions on the individual's access to glucagon administration in certain settings.

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