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Sample Medication Authorization Form

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Medication Authorization Form

For Prescription and Non-prescription Medications

VDSS Division of Licensing Programs Model Form

INSTRUCTIONS:

Section A must be completed by the parent/guardian for ALL medication authorizations.

Section A and Section B must be completed for any long-term medication authorizations (those

lasting longer than 10 working days).

Section A: To be completed by parent/guardian

Medication authorization for: __________________________________________________________

(Child’s name)

_____________________________________has my permission to administer the following medication:

(Name of Child Care Provider)

Medication name: _____________________________________________________________________

Dosage and times to be administered: _____________________________________________________

Special instructions (if any): _____________________________________________________________

____________________________________________________________________________________

This authorization is effective from: __________________________until: ______________________

(Start date)

(End date)

Parent’s or Guardian’s Signature: ______________________________________ Date: _____________

Section B: to be completed by child’s physician

I, ________________________________________ certify that it is medically necessary for the medication(s) listed

(Name of Physician)

below to be administered to:____________________________________ for a duration that exceeds 10 work days.

(Child’s name)

Medication(s): _________________________________________________________________________________

Dosage and Times to be administered: ______________________________________________________________

Special instructions (if any): _______________________________________________________________

______________________________________________________________________________________

This authorization is effective from: __________________________until: _______________________

(Start date)

(End date)

Physician’s Signature: ________________________________________________ Date: ___________________

Physicians Phone: _______________________________

032-05-0570-05-eng (06/12)

Sample Medication Authorization Form

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