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PM FORM 3151 -08-01-04 - Northern Arizona Regional - narbha-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the person's name and ID number at the top of the form. This information is essential for identifying the patient.
- In the medication section, list each medication prescribed along with its target symptoms. Ensure you specify symptoms rather than diagnoses.
- For each medication, indicate how it was discussed (e.g., in-person, telephone, tele-medicine) by checking the appropriate box.
- The person or guardian should initial and date next to each medication listed, confirming their understanding and consent.
- The behavioral health medical practitioner must also initial and date beside their printed name after discussing the medications.
- Finally, ensure that all signatures are collected and that a copy of this informed consent form is stored in the patient's file as required.
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