Medication Authorization Form - C Prescriber Authorization Form printable pdf download

HILLIARD CITY SCHOOL DISTRICT

MEDICATION AUTHORIZATION FORM - C

PRESCRIBER AUTHORIZATION

PURPOSE: Completion of this form is necessary to comply with the Ohio Revised

Code 3313.713 & 3313.718 and Hilliard Board of Education policy.

INJECTABLE MEDICATION

Name of Student: __________________________________________ DOB: ________________

Medication: ___________________________________ Dosage: _________________________

Route: ______________________________ Time: ____________________________________

FOR TREATMENT OF:

__ Medical diagnosis of: ______________________________________________________

__ STING ALLERGY - Specify insect if known: ____________________________________

__ FOOD/SUBSTANCE ALLERGY - Child may have an anaphylactic reaction to: _________

_______________________________________________________________________

Circumstances under which this medication should be administered: ___________________________

_________________________________________________________________________________

NOTE: SCHOOL PERSONNEL WILL CALL 911 WHEN AN EPIPEN IS ADMINISTERED.

Any additional emergency follow up: ________________________________________________

Is student able to self-carry and self-administer auto-injector? ____ YES* ___NO**

* By checking “yes” above, I acknowledge that I have deemed the student capable of

possession and self-administration of the auto-injector and have provided them with

appropriate training. I also understand that I must prescribe at least two injectors for

use at school, as required by ORC 3313.718.

** If the prescriber or school nurse determines the student to be incapable of possession

or self-administration, the auto-injector will be stored and administered as deemed

appropriate by school officials and outlined as such in the student’s Emergency Care

Plan.

Instructions to be followed in the event the student is unable to self-administer and/or the medication

does not produce the desired result: ____________________________________________________

_________________________________________________________________________________

Possible side effects of medication: _________________________________________________

Beginning date: _____________ Expiration date: _____________ Today's date: ____________

PRESCRIBER’S SIGNATURE: ____________________________ Phone Number: ____________

NPI#__________________________

Approved Ohio ORP provider: Yes/ No

PRESCRIBER’S address/office stamp: _________________________________________________

Revised 04/16

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Medication Authorization Form - C Prescriber Authorization Form