Form 5523 "Medication Aide Experience Documentation Report" - Texas

What Is Form 5523?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 5523 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 5523 "Medication Aide Experience Documentation Report" - Texas

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Form 5523
November 2020-E
Medication Aide Program
Medication Aide Experience Documentation Report
1. Applicant Name (last, first, middle initial)
2. Social Security No.
3. Applicant Job Title
4. Place of Employment
5. Address (Street or P.O. Box)
6. City
7. State
8. ZIP Code
9. Phone Number (Including Area Code)
10. Type of Facility
11. Applicant Job Title
12. Nurse Aide Certification No. (if Applicable) 13. Type of Work Performed
14. Facility Administrator/Program Director/DON
, certify that I have employed
I,
from
(Facility Administrator/Program Director/DON)
(Applicant)
to
and that I know of my own knowledge that said person was employed continuously in this facility which is licensed under Health & Safety Code
Chapter 242, as a certified nurse aide, or in this facility which is a licensed Personal Care Facility under Health & Safety Chapter 247, or in this
State Supported Living Center, ICF-IDD as a nonlicensed direct care staff person under the direct supervision of a licensed nurse on duty or on
call.
, 20
On this
day of
, in
I certify under penalty of perjury that the information submitted is true and correct.
Signature — Facility Administrator/Program Director/DON
Facility Vendor No.
The State of
County of
Before me, a notary public in
County, Texas on this day personally appeared
(Facility Administrator/Program Director/DON)
whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purposes and consideration
therein expressed.
Given under my hand seal of office, this
day of
, 20
Signature — Notary
Place Notary Seal
or Stamp Here
Printed Name — Notary
Commission Expiration Date
Form 5523
November 2020-E
Medication Aide Program
Medication Aide Experience Documentation Report
1. Applicant Name (last, first, middle initial)
2. Social Security No.
3. Applicant Job Title
4. Place of Employment
5. Address (Street or P.O. Box)
6. City
7. State
8. ZIP Code
9. Phone Number (Including Area Code)
10. Type of Facility
11. Applicant Job Title
12. Nurse Aide Certification No. (if Applicable) 13. Type of Work Performed
14. Facility Administrator/Program Director/DON
, certify that I have employed
I,
from
(Facility Administrator/Program Director/DON)
(Applicant)
to
and that I know of my own knowledge that said person was employed continuously in this facility which is licensed under Health & Safety Code
Chapter 242, as a certified nurse aide, or in this facility which is a licensed Personal Care Facility under Health & Safety Chapter 247, or in this
State Supported Living Center, ICF-IDD as a nonlicensed direct care staff person under the direct supervision of a licensed nurse on duty or on
call.
, 20
On this
day of
, in
I certify under penalty of perjury that the information submitted is true and correct.
Signature — Facility Administrator/Program Director/DON
Facility Vendor No.
The State of
County of
Before me, a notary public in
County, Texas on this day personally appeared
(Facility Administrator/Program Director/DON)
whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purposes and consideration
therein expressed.
Given under my hand seal of office, this
day of
, 20
Signature — Notary
Place Notary Seal
or Stamp Here
Printed Name — Notary
Commission Expiration Date