Loving Place
PRN Authorization Letter

Dear Dr.

Re: Your patient: a resident of A Loving Place

To Receive nonprescription and prescription PRN medications, state licensing requires that either:
1) Your Patient be capable of determining his/her own need for the medication, or
2) For nonprescription medication only, be able to clearly communicate his/her symptoms.
If your patient cannot determine his/her need for a medication, or, clearly communicate the symptoms for a nonprescription medication then you, the physician, must be contacted before the PRN medication can be given. Your completion of this form will serve to document your patientís current ability to determine his/her own need for these medications. As a licensed care provider, it is my responsibility to monitor your patientís continued ability to determine his/her own need for PRN medications and inform you of any changes which indicate he/she can no longer make these decisions.
Thank you for your assistance.
Sincerely,

Signature: Title

Telephone: Date

Please check which circumstance describes your patient





The following prescription/s and nonprescription/s medications can be taken by this patient on a PRN basis:
 
Medication
Strength
Dose
Route
Indication
Dose not to exceed in 24 hours
1
2
3
4
5

Physician's Signature: Date