Healthcare FMM Document

FACILITY MEDICATION MANAGEMENT (FMM) AUTHORIZATION

Patient Information

Date of Birth:     Gender:

Insurance & Provider

Medical History & Current Medications

Authorization for Medication Management

I, the undersigned, hereby authorize Facility staff and authorized contractors to administer prescription and non-prescription medications to the patient named above in accordance with licensed prescriber orders and the Facility Medication Management policies. This authorization includes but is not limited to administration, storage, documentation, and disposal of medications.

I understand that medication administration carries risks including allergic reaction, adverse interaction with existing medications, and possible side effects. I acknowledge that the attending prescriber will determine clinical necessity; Facility staff will follow prescriber orders and standard protocols to minimize risk. I have been informed of potential benefits, which include symptom control, prevention of disease progression, and improved clinical outcomes.

I retain the right to refuse or withdraw this authorization at any time by submitting written notice to the Facility. Withdrawal of authorization will not affect actions lawfully taken prior to the Facility's receipt of such notice.

Authorize administration of medications per prescriber orders and facility protocols

Authorize PRN (as-needed) medications consistent with prescriber instructions

Authorize nursing staff to make time-of-day adjustments and medication route administration per nursing judgment and standing orders

Information Release & HIPAA Acknowledgment

By signing below I authorize the Facility and associated pharmacy providers to obtain, use and disclose medication-related information necessary to provide safe and effective medication management, including prescriptions, medication history, and medication adherence data. I understand that information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by privacy regulations.

I acknowledge receipt of the Facility's Notice of Privacy Practices, and that I have been informed of my rights to request restrictions, revoke this authorization in writing, and receive an accounting of disclosures as required by law.

Authorization expires on:

Additional Consents and Notices

I permit Facility staff to communicate medication-related information with the following designated persons (provide name and relationship):

I acknowledge that falsification of information or failure to disclose known allergies or adverse reactions may result in harm and release the Facility from liability for adverse outcomes resulting from such omissions.

Patient Attestation

By signing below I certify that I have read and understand this authorization, have had an opportunity to ask questions which were answered to my satisfaction, and that I am competent to make healthcare decisions for myself. If signing as a legal guardian, representative, or power of attorney, I certify that I have the legal authority to execute this authorization on the patient's behalf.

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