Medication Authorization and Release #1

PLEASE READ

All medication releases require a current well care visit. If patient is over the age of 3, a well care visit within the last 12 months. If patient is less than 3, a well care visit per AAP guidelines. Medically approved over the counter medicines will be approved per directions and age on label. Approved medications include:

Instructions For Receiving Forms

Please read this information as we have changed our process.
Please Note - At your annual Well Care visit you can request that your provider push a form to the My Health Connection Patient Portal. There is no charge for printing forms from your portal.
1. Payment is required prior to receiving your form.
2. Regardless of the method you choose to request a form, pre payment will be collected prior to submission.
3. If after reviewing your form request, we determine that payment is not necessary, you will be refunded.
4. Please select your turn around time below.
5. Add your credit card information
6. Complete the Form Request Information including how you would like the form returned.
7. Once our Medical Records Department has reviewed and completed your form, they will email you with the encrypted form attached.
8. If you have elected to pick up your form, you will receive an email letting you know its ready for pick-up at our East Elizabeth Office.

Turnaround Time and Payment Information*

7-10 Day TurnaroundYou may request up to 5 forms for the price listed. To add another form follow the instructions on the Thank You Page.

$10.00

Rush-Next Business Day TurnaroundYou may request up to 5 forms for the price listed. To add another form follow the instructions on the Thank You Page.

$40.00

Total

$0.00

Credit Card

Form Completion Information

Please complete the information below indicating your contact information, relationship to patient, how you would like to receive your form and you preferred method of delivery.
Person Requesting Form Name:*

First NameLast Name
Relationship To Patient*
Contact Phone*
Please enter a valid phone number.
Contact Email*
example@example.com
How Would You Like To Receive Your Form?*
Parent Completes
Student Name*
Student ID#
Date of Birth*

MonthDayYear
Date
Grade
School Year
School Student Attends
Fax Number
School/Activity where Medicine is to be Administered
Health Care Provider Authorization and Directions
Name of Medicine*
The Medicine is

PrescriptionNonprescription
Purpose of Medicine
Dosage
Route Of Administration
Time(s) the Medicine is to be Administered
Starting Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
Possible Side Effects Of Medication
Provider
Printed Name Of Health Care Provider
Office Phone
Please enter a valid phone number.
Parent/Guardian Request, Permission and Release
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Do You Require Another Medication Form? (Up To 5 Can Be Submitted)*
Turnaround Time
Should be Empty:

PLEASE READ

Instructions For Receiving Forms

Credit Card

Form Completion Information

Parent Completes

Health Care Provider Authorization and Directions

Provider

Parent/Guardian Request, Permission and Release