Form Dhmh-4758 - Maryland Medication Administration Authorization Form
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1
2Department of Health & Mental Hygiene (DHMH)
MEDICATION ADMINISTRATION
Center for Healthy Homes and Community Services (CHHCS)
AUTHORIZATION FORM
(410) 767-8417
Toll Free 1-877-4MD-DHMH ext. 8417
for Youth Camps in Maryland
This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the
camper to self-administer medication. A new medication administration form must be completed at the beginning of each camp season,
for each medication, and each time there is a change in dosage or time of administration of a medication.
Prescription medication must be in a container labeled by the pharmacist or prescriber.
Nonprescription medication must be in the original container with the instructions for use. Nonprescription medication includes
vitamins, homeopathic, and herbal medicines.
An authorized individual must bring the medication to the camp and give the medication to an adult staff member.
I. PRESCRIBER’S AUTHORIZATION
2. DATE OF BIRTH
1. CHILD’S NAME
___/___/______
Month
Day
Year
3. CONDITION FOR WHICH MEDICATION IS BEING ADMINISTERED:
4. EMERGENCY MEDICATION
[ ] YES
[ ] NO
-If yes, see Section III below.
5. MEDICATION NAME
6. DOSE
7. ROUTE
8. TIME/FREQUENCY OF ADMINISTRATION
9. IF PRN, FREQUENCY
10. IF PRN, FOR WHAT SYMPTOMS
11. KNOWN SIDE EFFECTS SPECIFIC TO CHILD
12. MEDICATION SHALL BE ADMINISTERED
12a. FROM
12b. TO
during the year in which this form is dated in 14b below unless more restrictive dates
___/___/______
___/___/______
are specified in 12a and 12b. This authorization is NOT TO EXCEED 1 YEAR.
Month
Day
Year
Month
Day
Year
13. PRESCRIBER’S NAME/TITLE
This space may be used for the Prescriber’s Address Stamp
TELEPHONE
FAX
ADDRESS
CITY
STATE
ZIPCODE
14a. PRESCRIBER’S SIGNATURE (Parent/guardian cannot sign here)
14b. DATE
(ORIGINAL SIGNATURE OR SIGNATURE STAMP ONLY)
II. PARENT/GUARDIAN AUTHORIZATION
I request the authorized youth camp operator, staff member or volunteer to administer the medication or supervise the camper in self-administration
as prescribed by the above authorized prescriber. I certify that I have legal authority to consent to medical treatment for the child named above,
including the administration of medication at the facility. I understand that at the end of the authorized period, an authorized individual, as listed in
15c below, which may include the child, must pick up the medication, otherwise it will be discarded. I authorize camp personnel and the authorized
prescriber indicated on this form to communicate in compliance with HIPAA.
15a. PARENT/GUARDIAN SIGNATURE
15b. DATE
15C. INDIVIDUAL(S) AUTHORIZED TO PICK UP MEDICATION
15d. HOME PHONE #
15e. CELL PHONE #
15f. WORK PHONE #
III. AUTHORIZATION FOR SELF-ADMINISTRATION / SELF-CARRY (OPTIONAL)
This section should only be completed if this medication is approved for self-administration. Self-carry is only permitted for emergency medications
such as inhalers and epinephrine. Both the prescriber and the parent/guardian must consent to self-administration below. However, youth camp
operators are not required to permit self-administration or self-carry.
I authorize self-administration of the above listed medication for the child named above under the supervision of the youth camp operator, a
designated staff member or volunteer. If indicated below, the child named above may self-carry emergency medication.
16a. PRESCRIBER’S SIGNATURE
16b. SELF-CARRY EMERGENCY MEDICATION (Check One)
16c. DATE
authorizing self-administration
[ ] YES
[ ] NO
[ ] N/A - Not emergency medication
17a. PARENT/GUARDIAN’S SIGNATURE
17b. SELF-CARRY EMERGENCY MEDICATION (Check One)
17c. DATE
authorizing self-administration
[ ] YES
[ ] NO
[ ] N/A - Not emergency medication
DHMH-4758 (01/2017)
Page 1 of 1
KEEP FOR 3 YEARS
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