Medication Authorization Form – Martinez Heart & Home Care

⚠️ Important: Medication services are provided only when legally permitted, appropriately authorized, and included in the client's plan of care per DSHS regulations. This form must be completed before any medication assistance can begin.

Medication #1

Medication Name *

Dosage / Strength *

Frequency *

Time(s) to Give

Route

Purpose / Condition Treated

Special Instructions

Medication #2

Medication Name

Dosage / Strength

Frequency

Time(s) to Give

Route

Purpose / Condition Treated

Special Instructions

Please indicate what medication assistance you are authorizing Martinez Heart & Home Care to provide:

Remind client to take medications at scheduled times Retrieve medications and bring them to the client Open medication containers and assist client in self-administering Administer oral medications as prescribed (within permitted scope) Apply topical medications as prescribed (within permitted scope) Document medication administration in the Medication Administration Record (MAR) Report missed, refused, or concerning medication events to the care coordinator and/or family

In a medication emergency, caregiver should:

Call 911 immediately, then notify family Notify family first, then call 911 if directed Contact prescribing physician first

By signing below, I authorize Martinez Heart & Home Care to provide medication assistance as indicated above. I understand that medication services are provided only within the agency's permitted scope and applicable legal requirements. I certify that all information provided is accurate and complete.

All fields marked * are required.

DSHS WAC 388-71 Compliant. Form MHH-05.

💊 Medication Authorization Form

✅ Medication Authorization Submitted!