Form 5534 "Medication Aide General Statement Enrollment" - Texas

What Is Form 5534?

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 5534 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 5534 "Medication Aide General Statement Enrollment" - Texas

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Form 5534
November 2020-E
Medication Aide Program
General Statement Enrollment
All required forms must be completed and returned to the above address no later than 20 days after the date of the first scheduled class in
which you are enrolled. Include a $25.00 Nonrefundable combined application & examination fee made payable to the Texas Health and
Human Services Commission (HHSC).
If any portion of the application is incomplete, if fee is not included or if documentation is missing, the application cannot be processed.
2. Social Security No.
1. Name (last, first, middle initial)
3. Mailing Address (Street or P.O. Box)
4. Home Phone No. (Including Area Code)
City
State
ZIP Code
5. Date of Birth (mm/dd/yyyy)
6. Name of Approved Training School
7. City of Approved Training School
City
State
ZIP Code
8. Date of First Scheduled Class of Instruction (mm/dd/yyyy):
Yes
No
9. Are you able to read, write, speak and understand English?
Yes
No
10. Are you at least 18 years old?
11. Submit an Experience Documentation Report form documenting current employment of the first official day of the training program in a
facility licensed under Health and Safety Code Chapter 242 in the capacity of a certified nurse aide or in an assisted living facility licensed
under Health and Safety Code 247, state supported living center, or ICF-IDD facility as a non-licensed direct care staff person. (home health
are not licensed facilities under the medication aide regulations).
12. Submit an Experience Documentation Form documenting 90 days of employment in an assisted living facility licensed under Health and
Safety Code 247, state supported living center or ICF-IDD facility as non-licensed direct care staff. This employment must have been
completed. Within the 12-month period preceding the first official class date. An applicant employed as a certified nurse aide is exempt
from the 90-day requirement.
13. Submit a certified copy or a photocopy which has not been notarized as a true copy of an unaltered original of a high school graduation
diploma or transcript or a general equivalency diploma
14. Are you, to the best of your knowledge, free of contagious diseases and in suitable physical
Yes
No
and emotional health to safely administer medications?
15. Are you listed on the Employee Misconduct Registry (EMR) as unemployable?
Yes
No
16. Have you been convicted of a criminal offence listed in Texas Health and Safety Code §250.006?
Yes
No
If yes, list date
and conviction
Yes
No , if no obtain a copy from the training
17. Have you received a copy of the Medication Aide Training Program Rules?
program or call this office.
With few exceptions, you have the right to request and be informed about the information that THHSC obtains about you. You are entitled to
receive and review the information upon request. You also have the right to ask THHSC to correct information that is determined to be
incorrect. (Government Code Sections 552.021, 552.023, 559.004) To find out about your information and your right to request correction,
please contact this office.
Form 5534
November 2020-E
Medication Aide Program
General Statement Enrollment
All required forms must be completed and returned to the above address no later than 20 days after the date of the first scheduled class in
which you are enrolled. Include a $25.00 Nonrefundable combined application & examination fee made payable to the Texas Health and
Human Services Commission (HHSC).
If any portion of the application is incomplete, if fee is not included or if documentation is missing, the application cannot be processed.
2. Social Security No.
1. Name (last, first, middle initial)
3. Mailing Address (Street or P.O. Box)
4. Home Phone No. (Including Area Code)
City
State
ZIP Code
5. Date of Birth (mm/dd/yyyy)
6. Name of Approved Training School
7. City of Approved Training School
City
State
ZIP Code
8. Date of First Scheduled Class of Instruction (mm/dd/yyyy):
Yes
No
9. Are you able to read, write, speak and understand English?
Yes
No
10. Are you at least 18 years old?
11. Submit an Experience Documentation Report form documenting current employment of the first official day of the training program in a
facility licensed under Health and Safety Code Chapter 242 in the capacity of a certified nurse aide or in an assisted living facility licensed
under Health and Safety Code 247, state supported living center, or ICF-IDD facility as a non-licensed direct care staff person. (home health
are not licensed facilities under the medication aide regulations).
12. Submit an Experience Documentation Form documenting 90 days of employment in an assisted living facility licensed under Health and
Safety Code 247, state supported living center or ICF-IDD facility as non-licensed direct care staff. This employment must have been
completed. Within the 12-month period preceding the first official class date. An applicant employed as a certified nurse aide is exempt
from the 90-day requirement.
13. Submit a certified copy or a photocopy which has not been notarized as a true copy of an unaltered original of a high school graduation
diploma or transcript or a general equivalency diploma
14. Are you, to the best of your knowledge, free of contagious diseases and in suitable physical
Yes
No
and emotional health to safely administer medications?
15. Are you listed on the Employee Misconduct Registry (EMR) as unemployable?
Yes
No
16. Have you been convicted of a criminal offence listed in Texas Health and Safety Code §250.006?
Yes
No
If yes, list date
and conviction
Yes
No , if no obtain a copy from the training
17. Have you received a copy of the Medication Aide Training Program Rules?
program or call this office.
With few exceptions, you have the right to request and be informed about the information that THHSC obtains about you. You are entitled to
receive and review the information upon request. You also have the right to ask THHSC to correct information that is determined to be
incorrect. (Government Code Sections 552.021, 552.023, 559.004) To find out about your information and your right to request correction,
please contact this office.
Form 5534
Page 2 / 10-2020-E
Please Read Carefully
In making application to the HHSC Medication Aide Program for the issuance of a permit as a Medication Aide, I have read and agree to abide
by the Medication Aide Training Program rules. I also agree to complete all application requirements and take all examinations necessary for
the processing of my application. Upon issuance of a permit, I agree to be bound by the Allowable and Prohibited Practices of a Permit Holder
(TAC 557.105). I further understand that the materials submitted for consideration become the property of the department and are non-
returnable. I am aware of the schedule of fees (TAC 557.109(c)) and understand that additional fees must be paid to keep the permit current
I further agree that if issued a permit, upon the denial, suspension or revocation of that permit, I shall return the permit to the department.
The information that I have provided in this application is truthful. I understand that to falsify any information submitted to the HHSC may result
in voiding of this application, failure to be granted a permit or the revocation of my permit.
Signature — Applicant
Date
The State of
County of
BEFORE ME, the undersigned authority, on this day personally appeared
, known to me to be the person whose
name is subscribed to the foregoing instrument, and having been by me first duly sworn on oath, acknowledged that he/she had executed the
same for the purposes and consideration therein expressed and the foregoing statements are true and correct.
Given under my hand seal of office, this
day of
, 20
Notary Public in and for
County, Texas or
Signature — Notary
Place Notary Seal
or Stamp Here
Printed Name — Notary
Commission Expiration Date
Medication Aide Program
P. O. Box 149030
Mail Code E-416 Austin, Texas 78714-9030
With a few exceptions, you have the right to request and be informed about the information that the HHSC obtains about you. You are entitled
to receive and review the information upon request. You also have the right to ask HHSC to correct information that is determined to be
incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction,
please contact the Long Term Care Regulatory Medication Aide Program at 512-438-2025.
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