Form 2404, Documentation of Licensed Vocational Nurse Required Supervision

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Documents

Effective Date: 1/2009

Instructions

Updated: 9/2008

Purpose

To document that the Medically Dependent Children Program (MDCP) Licensed Vocational Nurse (LVN) provider is in compliance with Section 301.353 of the Occupations Code and 22 Texas Administrative Code §217.11.

Detailed Instructions

Printed Name of Licensed Vocational Nurse (LVN)— Enter the legal name of the MDCP LVN provider.

Contract No.— Enter the provider contract number.

I meet this requirement. I am supervised by:— Mark the box of the type of professional who is supervising you: Licensed Physician, registered (RN) or physician's assistance (PA).

1., 2. or 3.— Enter the name of the person supervising you on the line next to the type of professional supervising you. Enter the persons street address, city, state, ZIP code, area code and telephone number, and the person's license number.

Signature of LVN— Sign and date the document.

License No.— Enter your LVN license number.

Signature of Physician, RN or PA— The physician, RN or PA who is supervising must sign and date the document.