TX HHS Form H1700-2. Individual Service Plan Addendum
Form 5502-MA is the official application used in Texas by nursing graduates and nursing students who want to obtain a Medication Aide permit through the Health and Human Services Commission (HHSC). This form allows eligible applicants to seek authorization to administer medications in licensed nursing facilities or intellectual disability facilities while they are not yet licensed as professional or vocational nurses.
Purpose of Form 5502-MA
The purpose of Form 5502-MA is to determine whether a nursing graduate or nursing student meets the legal, educational, and background requirements to participate in the Medication Aide Program. Approval of this application allows the applicant to sit for the required examination and, if successful, receive a Medication Aide permit.
The form also serves as a formal declaration that the applicant understands and agrees to follow state rules governing medication administration and professional conduct.
When This Form Must Be Submitted
Form 5502-MA must be submitted when a nursing graduate or eligible nursing student applies for a Medication Aide permit in Texas. Common situations include:
- A recent graduate of an accredited school of nursing who is not yet licensed as a nurse
- A nursing student who has completed qualifying coursework
- An unlicensed direct care staff member seeking expanded medication administration duties
- A nurse aide working in a nursing facility who meets eligibility criteria
This form should not be used by individuals who already hold an active professional or vocational nursing license that predates the eligibility cutoff described in state rules.
Who Is Authorized to Complete the Form
The application must be completed by the individual applicant. Employers, schools, or facilities may assist with documentation, but the applicant is responsible for completing Section 1 and signing Section 2 in front of a notary.
Explanation of Key Sections
Section 1 – Applicant Information
This section collects personal, educational, and eligibility information. The applicant must provide identifying details, contact information, and the name of the accredited school of nursing attended. Applicants must also indicate whether they are a graduate or a current or former student and provide relevant dates.
Several eligibility questions confirm age, English proficiency, employment status, health status, registry standing, and criminal history.
Educational Status and Licensing Questions
This portion clarifies whether the applicant has graduated or attended an accredited nursing program and whether they currently hold, or have ever held, a nursing license or temporary permit. These answers are critical for determining eligibility under state rules.
Criminal History and Registry Disclosures
Applicants must disclose whether they are listed on the Employee Misconduct Registry or have convictions under Texas Health and Safety Code Section 250.006. Honest disclosure is required, as this information is verified independently.
Section 2 – Applicant Signature and Notarization
This section contains legally binding statements. By signing, the applicant agrees to complete fingerprint-based criminal history checks, follow Medication Aide Program rules, pay required fees, and comply with allowable and prohibited practices. The signature must be notarized.
Legal and Regulatory Context
Form 5502-MA is governed by Texas Administrative Code Chapter 557, which regulates the Medication Aide Program. These rules establish eligibility requirements, training standards, examination procedures, and disciplinary authority.
Submitting false or misleading information may result in denial of the application, revocation of a permit, or other administrative action.
Practical Tips for Completing Form 5502-MA
- Review eligibility rules carefully before applying.
- Ensure all supporting documents are notarized when required.
- Submit the application through your TULIP account, not by mail.
- Complete fingerprinting early to avoid delays.
- Double-check school information and transcript accuracy.
Common Mistakes to Avoid
- Failing to notarize Section 2
- Submitting incomplete or unofficial transcripts
- Omitting required supporting forms
- Providing inconsistent education or licensing dates
- Delaying fingerprint background checks
Real-Life Examples of When This Form Is Used
- A nursing graduate awaiting licensure applies to become a Medication Aide.
- A nursing student working in a long-term care facility seeks authorization to administer medications.
- An unlicensed direct care worker expands responsibilities after completing nursing coursework.
Documents Commonly Submitted with This Form
- Form 5503-MA, Verification of Curriculum
- Notarized high school diploma
- Notarized official nursing school transcript
- Fingerprint criminal history check confirmation
Frequently Asked Questions
Does submitting Form 5502-MA guarantee a permit?
No, approval depends on eligibility, background checks, and examination results.
Where is the application submitted?
It must be submitted through the HHSC TULIP online system.
Is fingerprinting required?
Yes, a fingerprint-based criminal history check is mandatory.
Who must notarize the form?
A Texas-authorized notary public must witness the signature.
Can employers submit this form?
No, the applicant must submit it personally.
What happens if information is falsified?
The application may be denied or an issued permit revoked.
Related Forms
- Form 5503-MA – Verification of Curriculum
- Form 5503 – Medication Aide Application (Other Categories)
- TULIP Nursing Applications
Form Details
- Form Name: Medication Aide Application for Nursing Graduates and Nursing Students
- Form Number: 5502-MA
- Issued By: Texas Health and Human Services Commission
- State: Texas
- Revision Date: May 2024