Texas HHS Form 5523, the Medication Aide Experience Documentation Report, is a supporting document your employer completes and signs to verify that you have the direct care work experience required for a medication aide permit. You gather it, your facility administrator or director of nursing fills it out and signs it, a notary certifies the signature, and you upload the finished form to the TULIP portal with the rest of your application. You do not fill in the employment and verification sections yourself.
What the Form Does
Form 5523 proves to Texas Health and Human Services that you have hands-on experience in a qualifying care setting before the state lets you sit for the medication aide competency exam. The Medication Aide Program operates under Chapter 242, Subchapter N of the Texas Health and Safety Code, with a second statutory basis under Chapter 142, Subchapter B for home and community support services agencies.1Texas Health and Human Services. Medication Aide Program
The current version of the form is effective June 2024 and is available on the Texas HHS forms page.2Texas Health and Human Services. Form 5523, Medication Aide Experience Documentation Report Without a properly completed and notarized copy in your application package, your file stalls.
Who Uses Form 5523 and Who Uses a Different Form
Form 5523 is for applicants on the traditional initial route and for reciprocity applicants coming in from another state. Two other routes use different paperwork:3Texas Health and Human Services. Become a Medication Aide in Texas
- Nursing students and graduates apply using Form 5502-MA along with a curriculum verification form (5503-MA). Form 5523 is not typically required.
- Correctional medication aide applicants, whose program runs through the Texas Department of Criminal Justice, use Form 5541 for experience documentation.
If you are on the traditional route, you complete an approved 100-hour training program while working at a qualifying facility, and Form 5523 documents that employment.
Experience Your Employer Is Certifying
Your administrator cannot truthfully sign the form unless the underlying facts are true. Texas rules require that on the first day of your medication aide training class you are employed at a qualifying facility as a nurse aide or non-licensed direct care staff person, and that you have at least 90 days of direct care work experience within the past 12 months. Certified nurse aides employed in a Medicare skilled or Medicaid nursing facility are exempt from the 90-day waiting period.3Texas Health and Human Services. Become a Medication Aide in Texas
Qualifying facilities include those licensed under Health and Safety Code Chapter 242 (nursing and convalescent homes), personal care facilities licensed under Chapter 247, state supported living centers, and intermediate care facilities for individuals with intellectual disabilities (ICF-IID).
Completing the Form Section by Section
Applicant Information
The top block identifies you. It asks for your full name (last, first, middle initial), Social Security number, job title, place of employment, and the facility’s address and phone number, along with the type of facility. If you already hold a nurse aide certification, put that certification number in the space provided. This is the only part of the form you can reasonably prefill before handing it to your administrator.
Employment and Experience Verification
The core of the form is completed by your facility administrator, program director, or director of nursing. They verify:
- Your employment dates at the facility, including start date and whether you are still employed.
- The type of direct care work you performed.
- The type of facility, tied to its licensing status under Chapter 242, Chapter 247, or its status as a state supported living center or ICF-IID.
- The facility’s vendor identification number assigned by HHSC.
The administrator then signs. The signature is the facility’s official confirmation that you worked there in a qualifying role, and no other signature substitutes for it.
Notarization
Once the administrator signs, a notary must certify the signature. The notary block records the county, date, notary’s signature, printed name, and commission expiration. A form arriving at HHSC without notarization gets rejected, so treat this as part of the completion step rather than something to handle later. In practice, that means either arranging for the administrator to sign in front of a notary the first time, or coordinating a same-day signature and notary visit. Some larger facilities keep a notary on staff.
Submitting the Form With Your Application
Since July 5, 2023, all medication aide permit applications go through the Texas Unified License Information Portal (TULIP) at tulip.hhs.texas.gov.1Texas Health and Human Services. Medication Aide Program You create an account, upload your notarized Form 5523 along with the other required documents, pay the fee, and submit.
Form 5523 travels with the rest of the traditional-route package. The HHS Medication Aide Program Forms page lists the full set of program forms, including Form 5534, the General Statement Enrollment form for your training program, which also requires notarization.4Texas Health and Human Services. Medication Aide Program Forms
If you are concerned that a prior criminal conviction could affect your eligibility, you can request a criminal history evaluation letter from HHSC before you start training. Contact the Medication Aide Program by email to get the required service code.
Fees
The application and exam fee is $25 for the traditional, nursing student and graduate, and reciprocity routes. The correctional route fee is $15.3Texas Health and Human Services. Become a Medication Aide in Texas You pay in TULIP at the time you submit.
After You Submit
Once your application, including a properly signed and notarized Form 5523, is accepted in TULIP, HHSC arranges scheduling of your competency exam through a regional exam proctor working with your training school. Your school notifies you of the date. Keep a copy of your notarized Form 5523 with your own records in case any part of the submission needs to be reproduced.