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Get LA OCDDWSS-PF-11-001

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 authorized attendant medication dosage treatment or instructions require the completion of a new form prior to implementation of the change. 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 authorized attendant medication dosage treatment or instructions require the completion of a new form prior to implementation of the change. .

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Keywords relevant to LA OCDDWSS-PF-11-001

  • developmental
  • herein
  • participant
  • medicaid
  • Revised
  • delegation
  • provider
  • medications
  • Completion
  • administer
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