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Authorization to Provide Medically Prescribed Treatment

Release and Indemnification Agreement

About this Form

Form number: 525-12

Audience:  Attending Physician, Parents/Guardians

Last revised: February 2017

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INSTRUCTIONS/INFORMATION:  “Medically prescribed treatment” does not mean “medical services” as defined in the regulations of the Individuals with Disabilities Education Act, 34 C.F.R. Section 300.13, and/or the Code of Maryland Regulations, 13A.05.01.02. This form is to be used in consultation with the School Community Health Nurse for treatments such as: urinary catheterization, tracheostomy, gastrostomy feedings, and oral suctioning. These are only illustrations of typical treatments and not an all inclusive listing. Consult with School Community Health Nurse for further information.

  1. The parent/guardian is responsible for obtaining the authorized prescriber's instructions (Part II) on this form, signing it (Part I) and returning it to the school. It is valid only during the school year in which it was signed. A new form must be submitted each year, and each time there is a change in medical treatment or conditions under which the treatment is given.
  2. The principal and/or SCHN will ensure that all items on the form are completed. This form must be on file in the student’s health folder.
  3. It is the responsibility of the parent/guardian to furnish the equipment necessary to provide the treatment and to maintain the equipment in good working order. Further, it is the responsibility of the parent/guardian to collect any equipment provided no later than one week after the end of the school year.
  4. Medical treatments will not be administered in school or during school sponsored activities without the parent’s/guardian’s signed authorization and waiver and an authorized prescriber's statement.
  5. The SCHN will call the prescriber, as allowed by Health Insurance Portability and Accountability Act of 1996 (HIPAA), if a question arises about the student and/or the student’s prescribed treatment.
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Release and Indemnification Agreement
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