HRSA Prescription Form PDF Details

The Health and Recovery Services Administration (HRSA) Prescription Form is a crucial document designed for healthcare practitioners to authorize the use of medical supplies and medications for patients, underlining its significance in the continuum of care. This form, with a validity of one year from the date it is signed, ensures that patients receive the necessary care tailored to their specific diagnosis and length of need. It is meticulously divided into sections that demand detailed information about the patient, including their name, date of birth, diagnosis, and whether the need for the prescribed item is less than or greater than six months, providing an option to specify the number of months if necessary. Additionally, it requests details about the item needed, quantity, and the frequency of use, thereby covering all bases to ensure the patient’s needs are comprehensively met. The form also includes a section for the physician’s printed name, contact information, and a statement certifying the accuracy of the provided information, underlining the responsibility of the physician in the prescription process. The declaration against falsification, omission, or concealment of material facts emphasizes the legal and ethical importance of honesty in filling out the form. By necessitating the physician’s signature, the form further validates the prescription, prohibiting the use of signature and date stamps to ensure authenticity. With its comprehensive design and strict requirements, the HRSA Prescription Form plays a pivotal role in the healthcare system by facilitating the necessary administrative process to deliver patient care efficiently and effectively.

QuestionAnswer
Form NameHRSA Prescription Form
Form Length1 pages
Fillable?Yes
Fillable fields47
Avg. time to fill out9 min 43 sec
Other namesdshs hca 13 794, health and recovery services administration prescription form, hrsa prescription form, hrsa prescription fomr

Form Preview Example

HEALTH AND RECOVERY SERVICES ADMINISTRATION (HRSA) PRESCRIPTION FORM

This prescription is valid for one (1) year from date signed.

SECTION I

PATIENT’S NAME

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

DIAGNOSIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LENGTH OF NEED

 

 

 

 

 

 

 

 

 

 

 

Indicate rental if applicable

Less than 6 months

 

Greater than 6 months

Number of months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II

 

 

 

 

 

 

ITEM

 

 

QUANTITY

 

 

SUPPLIES – FREQUENCY OF USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III

 

 

 

 

 

 

PHYSICIAN’S PRINTED NAME

 

 

 

TELEPHONE NUMBER

 

FAX NUMBER

REFERRING PHYSICIAN’S NUMBER

 

 

 

 

 

 

 

 

 

 

PHYSICIAN’S ADDRESS

 

 

 

 

 

 

CITY

STATE

ZIP CODE

I certify that I am the physician identified in Section III of this form and that the medical necessity information in Section I and II is true, accurate, and complete, to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact in those sections may subject me to civil or criminal liability. (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTED).

PHYSICIAN’S SIGNATURE

DATE SIGNED

 

 

DSHS 13-794 (11/2006)

 

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