Medication Consent Forms

The Fresno County Mental Health Plan (FCMHP) requires contracted psychiatrists to obtain Medication Consent before prescribing medications to beneficiaries. The beneficiary or legal guardian must sign the Medication Consent form when starting a new medication and whenever a change in medication class or the addition of a new class of psychotropics occurs (e.g., adding an antidepressant to the medication regimen, changing from an antidepressant to an antipsychotic). This form must be made available in the beneficiary's primary language if the beneficiary is monolingual. Consent must be maintained in the medical record at all times.

FCMHP will have staff review this form during the annual medical record review. A provider’s credentialing status may be affected if the provider does not consistently obtain the beneficiary’s consent.

For your convenience, forms have been provided in all three threshold languages of Fresno County (English, Spanish, and Hmong), in both Adobe PDF format (suitable for printing out the form and completing it by hand) and in Microsoft Word Document format (suitable for completing the form electronically and then printing for signatures).

Medication Consent Forms (Adobe PDF)

• Informed Med Consent English (Printable form)(PDF, 604KB)
• Informed Med Consent Spanish (Printable form)(PDF, 599KB)
• Informed Med Consent Hmong (Printable form)(PDF, 581KB)

Medication Consent Forms (Microsoft Word)

• Informed Med Consent English (e-form)(DOC, 78KB)
• Informed Med Consent Spanish (e-form)(DOC, 74KB)
• Informed Med Consent Hmong (e-form)(DOCX, 33KB)