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    Med Informed Consent

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    prabha
    This document is a medication informed consent form for behavioral or psychiatric conditions. It contains information for both the provider and the parent/guardian. For the parent/guardian, it explains the risks and benefits of medication and counseling, how to monitor the effects of medication, and that consent can be withdrawn. It requires signatures from the physician, parent/guardian, and witness to authorize the recommended medication, dose, and instructions.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Med Informed Consent

    Uploaded by

    prabha
    46 views2 pages
    This document is a medication informed consent form for behavioral or psychiatric conditions. It contains information for both the provider and the parent/guardian. For the parent/guardian, it explains the risks and benefits of medication and counseling, how to monitor the effects of medication, and that consent can be withdrawn. It requires signatures from the physician, parent/guardian, and witness to authorize the recommended medication, dose, and instructions.

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    This document is a medication informed consent form for behavioral or psychiatric conditions. It contains information for both the provider and the parent/guardian. For the parent/guardian, it explains the risks and benefits of medication and counseling, how to monitor the effects of medication, and that consent can be withdrawn. It requires signatures from the physician, parent/guardian, and witness to authorize the recommended medication, dose, and instructions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    46 views2 pages

    Med Informed Consent

    Uploaded by

    prabha
    This document is a medication informed consent form for behavioral or psychiatric conditions. It contains information for both the provider and the parent/guardian. For the parent/guardian, it explains the risks and benefits of medication and counseling, how to monitor the effects of medication, and that consent can be withdrawn. It requires signatures from the physician, parent/guardian, and witness to authorize the recommended medication, dose, and instructions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Page 1 of 2

    Medication Informed Consent Document


    For Behavioral or Psychiatric Conditions

    FOR PA REQUEST FOR MEDICAID BENEFICIARIES, FAX FORM TO Fax 1-800-424-5739


    Physician AR Medicaid ID Number: Recipient Medicaid ID Number:

    Physician Name: Patient Name:

    Address Address:

    City: State: Zip: City: State: Zip:

    Phone: ( ) Patient's Date of Birth: / /

    Fax: ( )

    PARENTAL/GUARDIAN CONSENT STATEMENT


    I understand:
     With or without medicine, counseling is important to help change behavior.

     Medicine may help manage some symptoms.

     What to expect without treatment, with counseling only, with medicine only, and with both counseling and
    medicine.

     I can refuse the use of this or any other medicine at any time.

     Medicines may sometimes cause behavior or health problems. Sometimes these affects may be permanent.

     I was given an information sheet about the recommended medicine. The sheet tells about:
    o FDA approval (if any) for using the medicine in children
    o Any safety concerns
    o How to stop taking the medicine
    o What to do about missing a dose
    o How to keep track of the effects of the medicine

     The effects and risks of this medicine may change over time. My child will need regular visits with the doctor to
    make sure it is safe to keep using the medicine.

    V072814
    Page 2 of 2

    PROVIDER SECTION:

     Targeted symptoms (signs and symptoms identified by the provider for treatment with antipsychotic medication)
    _________________________________________________________________________________________

     A comprehensive mental health or developmental/behavioral evaluation has been performed: CIRCLE ONE:

    More than 12 months ago In the past 12 months Current referral No evaluation planned

    PAST CURRENT REFERRED NO


     Patient and/or family counseling or behavioral intervention?    
    Provider comments: ____________________________________________________________________________

    _____________________________________________________________________________________________

    MEDICATION RECOMMENDATION DOSE DOSING INSTRUCTIONS (Please write clearly)


    A newly signed and dated form by all parties is required for changes in antipsychotic chemical entity or delivery system.

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    Medicines previously used: ___________________________________________________________________________

    __________________________________________________________________________________________________

    Other medicines continued or started: __________________________________________________________________

    _________________________________________________________________________________________________

    I have explained to the parent/guardian of patient via PHONE ____ or FACE-TO-FACE _____the risks
    and benefits of this medication. (Mark which method was used for education consultation)

    ______________________________________________/______________________ __________ ______


    PHYSICIAN, NURSE, or P.A. SIGNATURE (rubber stamp not allowed) /Print Name DATE TIME

    ____________________________________________________________________
    NAME OF PRESCRIBER Print Name Please

    As the parent/guardian of the patient named, I understand the risks and benefits of this medication
    as they have been explained to me and I consent to the use of the named medication.
    ______________________________/________ ______________ __________ _________ _____________
    PARENT/GUARDIAN SIGNATURE / Print Name DATE TIME RELATIONSHIP

    _______________________________________ __________ __________ _________


    WITNESS SIGNATURE DATE TIME

    V072814

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