CMS-07-021/023 - Los Angeles County Department of Children and ...

EXHIBIT A-X
2. Contact the physician and explain that the “Clinical Information” and “Medications”
sections of the PMAF (see NOTE) need to be completed in detail. Explain, if
necessary, what is required of the physician before the child can be treated with
psychotropic medications. Direct the physician to attempt to contact the parent/legal
guardian.
NOTE: It is the physician’s responsibility to explain to the parent/legal guardian
the need for the medication, possible side effects and so forth. It is also the
physician’s responsibility to obtain parental consent.
The “Medications” section of the PMAF must be completed by the prescribing
physician. The physician must list all prescribed medications the child currently
takes and will be taking if the request is granted, whether or not these were
prescribed by the requesting physician. The physician is encouraged to
indicate the range of dosages to be authorized. If the physician does not
indicate a range of dosages, a new PMAF will be required for each change in
the dosage schedule.
The prescribing physician must explain to the child, in age-appropriate terms:
• The recommended course of treatment,
• The basis for the treatment, and
• The possible results of taking the medication, including possible
side effects.
3. Inform the physician that a signed copy of the completed PMAF must be faxed to the DCFS
D-Rate Unit before the psychotropic medication may be prescribed.
5. Document in the child’s Contact Notebook all communications with the caregiver, the
physician and the parent/legal guardian regarding the psychotropic medication
authorization request.
NOTE: The DCFS D-Rate Unit will provide the CSW with a copy of the
physicians initial PMAF. This should be filed in the child’s
Psychological/Medical/Dental folder (purple).
6. The DCFS D-Rate Unit will provide the CSW and the PHN with a copy of the PMAF
containing the Court’s order. File a copy of the signed court order in the child’s
Psychological/Medical/Dental (purple) folder.
• If the court approves the psychotropic medication authorization, verify with the caregiver,
that the prescription has been filled and that the medication is being administered.
Document this information in the CWS/CMS Health Notebook.
NOTE: The PHN will document the court’s approval or denial of the PMAF
and other pertinent information related to the request (e.g., date the