FormsParents & StudentsHealth → Authorization to Provide Medically Prescribed Treatment

Authorization to Provide Medically Prescribed Treatment

Release and Indemnification Agreement

About this Form

Form number: 525-12

Audience:  Parents/Guardians, Attending Physician

Last revised: February 2019


Related Forms

Form 525-13 - Authorization to Administer Prescribed Medication

Form 525-14 - Emergency Care for the Management of a Student With a Diagnosis of Anaphylaxis

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 (SCHN) 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 SCHN 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.
Adobe PDF Authorization to Provide Medically Prescribed Treatment
Release and Indemnification Agreement
436 KEnglish
Adobe PDF AUTORIZACIÓN PARA PROVEER TRATAMIENTO MÉDICO PRESCRITO427 KSpanish
Adobe PDF AUTORISATION POUR ADMINISTRER DES TRAITEMENTS PRESCRITS PAR UN MÉDECIN429 KFrench
Adobe PDF GIẤY CHO PHÉP CUNG CẤP ĐIỀU TRỊ Y KHOA ĐƯỢC CHỈ ĐỊNH495 KVietnamese
Adobe PDF 提供醫藥處方治療授權書174 KChinese
Adobe PDF 처방전 약 투약 허가서457 KKorean
Adobe PDF በህክምና የታዘዘን የህክምና እርዳታ የመስጠት ስልጣን448 KAmharic

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat