MEDICATION RECEIPT, TRANSFER & DISPOSITION FORM Please complete this form when a youth is discharged from a facility or transported to another facility. Medications must be in the original pharmacy.
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How to fill out the FL HS 053 online
The FL HS 053 form is essential for documenting the receipt, transfer, and disposition of medications for youth being discharged or transported to another facility. This guide will provide you with clear, step-by-step instructions to help you complete the form accurately online.
Follow the steps to successfully complete the FL HS 053 form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the youth's name in the 'Name of Youth' section, followed by their DJJID# and date of birth (DOB). Ensure this information is accurate as it identifies the youth in the system.
- Next, record any allergies the youth may have in the designated field to ensure appropriate care during their medication management.
- In the 'Originating Facility' section, fill in the facility or program name, along with the complete address including city and state, and provide the phone number for the originating facility.
- Then, move to the 'Destination Facility' section, where you will enter the facility or program name and address, including city and state, along with the date and time of transfer.
- List each name of medication being transferred, ensuring all details are clear, and fill in the prescribing physician's information along with their contact telephone number.
- Mark the verification checkbox for each medication to confirm it has been checked for completeness and accuracy.
- Complete the 'Intake Medications Receipt' portion if you are bringing medications from home, detailing the strength and including the printed name and signature of the person delivering the medications and the DJJ staff.
- Document the printed name and title of the person accepting the medications within the facility and ensure signatures are provided by both the parent/guardian and staff.
- Finally, ensure you understand the release statement regarding the acceptance of medications in non-child-proof containers, then sign and date as required.
- Once all information is accurately filled, you can save changes, download, print, or share the completed form as needed.
Complete your FL HS 053 form online today for a smooth transition of care.
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