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NOTICES

BUREAU OF PROFESSIONAL AND
OCCUPATIONAL AFFAIRS

Consent Form for Prescribing Opioid Medications to a Minor

[47 Pa.B. 671]
[Saturday, February 4, 2017]

 The act of November 2, 2016 (P.L. 983, No. 125) (Act 125) added 35 Pa.C.S. Chapter 52A (relating to prescribing opioids to minors). Under 35 Pa.C.S. Chapter 52A, the Bureau of Professional and Occupational Affairs (Bureau) has the authority to prescribe the consent form to be executed by the minor's parent, guardian or other authorized adult for the prescription of opioid medication to a minor as required under 35 Pa.C.S. § 52A04(a)(3) (relating to procedure). Therefore, in accordance with 35 Pa.C.S. § 52A02(b)(2) (relating to administration), the Commissioner of Professional and Occupational Affairs provides notice of the approval of the following written consent form, which is available on the Bureau's web site at www.dos.pa.gov/ProfessionalLicensing. In accordance with section 2 of Act 125, the provisions of 35 Pa.C.S. §§ 52A03—52A05 are effective upon the publication of this notice.

IAN J. HARLOW, 
Commissioner

CONSENT TO PRESCRIBE OPIOID MEDICATION TO A MINOR

Background: Pennsylvania law requires that in most non-emergency circumstances, a minor may only be prescribed opioid medications (morphine-like drugs) if the prescriber first discusses the potential risks associated with the medication with the minor and also with the minor's parent, guardian, or an adult who has a valid health care proxy to consent to the minor's medical treatment. This consent form memorializes that the prescriber discussed the risks associated with opioid medications with you and the minor-patient. Please review the information listed and put your initials next to each item after you and the minor-patient have discussed the risks with the prescriber and feel you understand and accept what each statement says.

Patient Name:
Patient's Date of Birth:
Name of Parent/Guardian/Authorized Adult:

___________________________      ______
  Signature of parent/guardian/authorized adult          Dated
      Circle the appropriate relationship

Name of Medication (brand or generic name):
Quantity:
Amount of initial dose:
Number of refills:*

The medication being prescribed above is a controlled substance containing an opioid. This means the medication has been identified by the United States Drug Enforcement Administration as having a potential for abuse, dependence or misuse.

 As the responsible prescriber, I certify that I have discussed with both the minor, as well as with the minor's parent/guardian/authorized adult the following items:

Adult Initial
(i) The risks of addiction and overdose associated with the controlled substance containing an opioid. ______
(ii) The increased risk of addiction to controlled substances to individuals suffering from mental or substance use disorders. ______
(iii) The dangers of taking a controlled substance containing an opioid with benzodiazepines, alcohol or other central nervous system depressants. ______
(iv) Any other information in the patient counseling information section of the labeling for controlled substances containing an opioid that I deemed necessary. ______

___________________________      ______
Signature of prescriber                       Dated

* If the adult consenting to treatment is someone other than a parent or guardian (i.e. an authorized adult acting pursuant to a valid health care proxy), the prescription for an opioid-containing drug must be limited to not more than a single, 72-hour supply and must indicate on the prescription the quantity that is be dispensed pursuant to the prescription. (35 Pa.C.S. 52A04(c))

This form must be maintained in the minor's record with the prescriber.

[Pa.B. Doc. No. 17-191. Filed for public inspection February 3, 2017, 9:00 a.m.]



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