TX HHS Form 5523. Medication Aide Experience Documentation Report

Form 5523 (June 2024) is used by the Medication Aide Program to verify an applicant’s employment history and hands-on experience in qualifying health care settings. This document must be completed by the facility administrator, program director, or director of nursing who supervised the applicant. The form serves as official proof that the applicant meets the practical experience requirements needed for medication aide credentialing.

Purpose of Form 5523

The main purpose of the form is to confirm that an applicant has worked in a facility where medication administration or direct care duties were supervised by a licensed nurse. It ensures that individuals applying for medication aide certification have the proper background and training.

Who Completes the Form

The applicant fills out the identifying information, while the remaining sections must be completed and certified by:

• Facility Administrator
• Program Director
• Director of Nursing

A notary public must also notarize the form.

Information Required on the Form

The form collects detailed information about both the applicant and the employer. Required fields include:

• Applicant’s full name and Social Security number
• Facility name, address, and phone number
• City, state, and ZIP code
• Type of facility (e.g., nursing facility, assisted living, state supported living center)
• Applicant’s job title and type of work performed
• Nurse aide certification number (if applicable)
• Facility Vendor Number

Employment Verification

The certifying official must provide the exact dates of employment and confirm that the applicant:

• was continuously employed during the stated period, and
• performed duties as a certified nurse aide or unlicensed direct care staff member under the supervision of a licensed nurse.

This verification is given under penalty of perjury, ensuring accuracy and compliance with state regulations.

Notarization Requirements

The form must be signed and notarized. The notary includes:

• Date of notarization
• County and state
• Notary’s printed name
• Commission expiration date
• Official seal or stamp

Use of the Completed Form

Once completed and notarized, Form 5523 becomes part of the applicant’s required documentation when applying for medication aide certification. It serves as an official employment record verifying the applicant’s direct care experience and supervised responsibilities in a health care environment.