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

EXHIBIT A-X
1. Instruct the caregiver to provide the Psychotropic Medication Authorization Form
(PMAF) to the physician.
2. Inform the physician that court approval is required, unless the court has issued
specific orders delegating psychotropic medication decision-making authority.
3. Explain to the physician that the “Clinical Information” and “Medications” sections of
the PMAF (see NOTE below) need to be completed in detail. Explain, if necessary,
what is required of the physician before the child can be treated with psychotropic
medications. When applicable (see NOTE below), direct the physician to attempt to
contact the parent/legal guardian.
NOTE: When the court has issued specific orders delegating psychotropic
medication decision making authority to a parent or legal guardian, the
physician must make a good-faith effort to obtain written parent/legal guardian
consent before prescribing psychotropic medication for the child. In these
cases, it is the physician’s responsibility to explain to the parent/legal guardian
the need for the medication, possible side effects and so forth.
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.
4. 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 (if applicable) 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