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STATE OF LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS Office for Citizens with Developmental Disabilities PHYSICIAN DELEGATION FOR MEDICATION ADMINISTRATION AND MEDICAL TREATMENTS Participant s NAME Medicaid Number DATE PROVIDER AGENCY NAME PHONE NO EMPLOYEE NAME One Name Per Page MEDICATION / TREATMENT DOSAGE / SITE INSTRUCTIONS I have provided the above named employee of the named Medicaid service provider agency with specific training and instructions concerning the administration of the medication s and medical treatment s listed. This employee is acting under my authority. DELEGATING PHYSICIAN S SIGNATURE PHYSICIAN S NAME ADDRESS CITY STATE ZIP I have been instructed concerning administration of the medication s and medical treatment s described above and agree to administer only these medications and treatments and to do so according to the instructions given. EMPLOYEE S SIGNATURE NOTE This form is valid only until there is any change in the approval granted herein. Changes in au....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232