Authorizations for Dispensing Medications Long-Term

Kansas Department of Health and Environment Bureau of Family Health Child Care Licensing Program 1000 SW Jackson, Suite 200 Topeka, KS 66612-1274 Phone: 785-296-1270 Fax: 785-559-4244 Website: www.kdheks.gov/kidsnet

Kansas Depactment Healt's and Invironment

Authorization for Dispensing Medications to Children and Youth Long-Term Medications (Prescription and Non-Prescription)

Prescription medications must be in their original containers labeled with the child's/youth's first and last name: the name of the licensed physician, physician assistant (PA or advanced practice registered nurse (APRN) who ordered the medication; the date the prescription was filled; the expiration date of the medication; and specific, legible instructions for administration and storage of the medication Administer the medication only to the child designated on the prescription label in accordance with the instructions on the label. Non-prescription medications can be given with written permission and direction from the parent orlegal guardian. Administer nonprescription medication from the original container labeled with the first and last name of the child/youth and according to the instructions on the label.

Name*

First NameLast Name

Date of Birth*

Date

Name of Medication (only one medication per authorization)*

Prescription OR Non Prescription

Reason for Medication

Dose

Time to be Given

Dose (Amount)

Start Date*

Date

Stop Date**

Date

Name of Licensed Physician, PA or APRN prescribing the medication

Phone # of Physician, PA or APRN

Date

Parent's Signature*

"Stop date not to exceed one year from the start date. A new authorization is to be completed any time the medication, dosage, times to be given, or instructions from the parent or health care provider change from the information included on this form. Additional copies of this form may be attached to this page if more space is needed to record the administration of the medication for up to one year if there are no changes in instructions. Above information must be completed on each page but the parent's signature is required only once per year.

THIS FORM is TO BE USED TO DOCUMENT ADMINISTRATION OF ONLY THE MEDICATION IDENTIFIED ABOVE. Designated Person to note any comments or remarks about the child's/youth's appearance and/or condition on the back of the form.

"Each designated person administering medication is to sign on the back side of this form and identify initials used above.