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Medication Disclosure & MAT Acknowledgment

Disclose all prescribed medications and acknowledge medication safety procedures.

Kura Solution

Appendix K — Medication Disclosure & MAT Acknowledgment

Disclose all prescribed medications and acknowledge medication safety procedures.

Resident Name *

Current Prescribed Medications

Prescribing Provider

Pharmacy

MAT Participation

YesNo

If yes, type

I agree to follow medication safety and storage procedures and to notify staff of changes.

Signatures

Resident Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Resident Printed Name *

Date *

Staff Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Staff Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.