Medication Transfer Log
Professional Medication Transfer Log template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Medication Transfer Log
TEMPLATE • Inspection-Ready AFH Standard
1. Medication Inventory & Pill Count Verification
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Reason for Transfer (Hospital, Family Visit, Discharge)
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. Receiving Party Identification & Chain of Custody
Provider Signature / Date
Resident / POA Signature / Date
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Document Section Breakdown (4 Sections)
Medication Inventory & Pill Count Verification
Itemized list of medications sent with resident, prescription numbers, and pill count.
Reason for Transfer (Hospital, Family Visit, Discharge)
Transfer destination, expected return date, and emergency dosage instructions.
Receiving Party Identification & Chain of Custody
Name and signature of transport driver, family member, or EMS paramedic.
Staff & Receiving Signature Acknowledgments
Caregiver releasing signature and receiving party confirmation of medication counts.
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