Formerly AlaMAP
MMC (Medication Management Clinic) Patient Intake Application
Clinic Address:1225 Huffman Mill Rd, Suite 102, Burlington, NC 27215
Mailing Address: P O Box 202, Burlington, NC 27216
Phone: 336-538-8440
Fax: 336-538-8449
All areas of application must be completed or your application will not be processed
MMC (Medication Management Clinic) Screening/Eligibility Requirements
•Individuals 18-64 years of age with no prescription insurance and Medicare patients in the coverage gap (DONUT Hole)
•Total household income at or below the 250% Federal Poverty Level
•Can not be eligible to receive prescription drug benefits from Veteran’s Administration, Medicaid, or Private Insurance.
•All prescriptions must come from an Alamance County physician. Other prescriptions may be honored from other
Physicians as long as the patient is a resident of Alamance County. Special permission is required for Charles Drew
Clinic, Scott Clinic, Prospect Hill Clinic or any FQHC/CHC Health center.
***Your Social Security number and status of legal residency are NOT required by Medication Management Clinic.
However, this information is required by some of the drug manufacturers providing low/no-cost medications to the
Medication Management Clinic program. We will tell you if you are prescribed one of the medications requiring this
information. If you choose not to provide us with your Social Security number and status of legal residency, we will be
unable to request medications on your behalf from the drug manufacturers requiring this information, and you must
obtain those medications outside the Medication Management Clinic program.
Demographic Information
Date________________________
Name: Last _________________________ First _________________________ MI _________
Street Address _________________________________________________________________
City __________________
State_____
Zip Code__________
Phone Numbers: (home) ( )_______________ (cell)(
)_______________ (work)(
)_____________
A current working phone number is required at all times
County:
Alamance
Guilford
Birth Date:
Ethnicity:
Sex:
Male
Orange
Social Security #:
month
Age______
Caswell
date
US Citizen or Legal Resident
Caucasian
Female
(***See Eligibility Requirements)
year
African-American
Marital Status:
Yes
Hispanic
Single
Asian
Married
No (***See Eligibility Requirements)
Other: __________________
Separated
Divorced
Widowed
Primary language other than English spoken in household: ___________________________
Total number of individuals living in household including yourself that provide income for you: _______
How many in household over age 18 are employed?____________________
Date_____________
Name:_____________________ DOB_____________
Are you currently employed?
Yes
No
Employer__________________ Phone (
)____________
If no, and you are not seeking employment, explain____________________________________
Date of last employment___/_____/____
Are you able to drive a car?
Yes
No
(if
no, is transportation available?
Spouse: ______________________ Employer_________________Phone (
No )
Yes
)___________
One Local Alternate Contact: 1) ______________________________ Phone: (
)__________
*Relationship to that contact (e.g. son, friend, etc.) _____________________________
What is the easiest way for you to learn?
Listening
I have trouble with:
Seeing
Reading
Hearing
Reading
Pictures/Video
Physical Abilities
English
Demonstration
None
Is there someone that is involved in your care that should be included in your Medication Review and
Eligibility appointments?
No
Yes Name/Relationship to patient:____________________________________________
You must have or obtain a physician in order to receive medications from MMC
Primary Physician: ______________________________ Phone (
)___________________
Name of Practice: ______________________________Approximate date of last visit__________________
Other Practitioners: 1)_____________________________ Phone (
)___________________
Address________________________________________________________________________
2)_____________________________ Phone (
)____________________
Address_________________________________________________________________________
Pharmacy:_______________________________________ Phone (
)____________________
Please indicate if you receive assistance through any of the following health clinics:
О Charles Drew О Prospect Hill О Scott Clinic О Open Door Clinic О UNC-Chapel Hill
О Other_______________________
What agency or individual referred you to our program?_______________________________
Insurance (Please check all that apply)
o
o
o
o
o
o
o
o
Medicare
Medicare Part “D”
Medicaid
State/Aid for families with Dependent Children
HMO / PPO
Private / Employer Insurance
Health Insurance Marketplace Plan/Exchange
No insurance
Do you receive or are you eligible for prescription benefits through your insurance?
Yes
No
MMC REQUIRES A COPY OF ALL INSURANCE CARDS
Are you a Veteran?
Yes
No
Are you eligible to receive medical care or medications from the VA?
Yes
No
Unsure
Have you applied for Medicaid?
Yes
No (if rejected, we need copy of denial letter)
Have you applied for Social Security Disability?
Yes
No (if rejected, we need copy of denial letter)
Date when you began receiving Social Security Disability ___/______/_______
Date________________
Name:_____________________ DOB_____________
Medical
***Allergies to medicines (Please list each allergy and the reaction you had to that medicine)
1)___________________________________
2)___________________________________________
3)____________________________________
4)___________________________________________
Health Problems: (Please check all that apply)
⃝ Heart
Failure ⃝ Angina ⃝ Heart Attack ⃝ Irregular heart beat ⃝ High blood pressure
High cholesterol ⃝ Stroke ⃝ Diabetes ⃝ Thyroid disease ⃝ Reflux disease ⃝ Cancer ⃝ Depression
⃝ Bipolar disorder ⃝ Schizophrenia ⃝ Arthritis ⃝ Asthma ⃝ COPD/Emphysema ⃝ Kidney disease
⃝ Osteoporosis ⃝ Glaucoma ⃝ Cataracts ⃝ HIV/AIDS ⃝ Tobacco use ⃝ Alcohol use
⃝ Other________________________________________________________________________________
⃝
Medications
Please list “ALL MEDICATIONS” (prescription, over-the-counter, herbals, and vitamins) you take. This
includes medications taken daily and medications taken only when you need them.
Name of Medicine
Example: Coreg
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Strength
12.5 mg
How You Take Your Medicine
One tablet twice a day
Prescribing Doctor
Dr. Jane Doe
Please bring all medication(s) in their original bottle(s). This includes prescription, overthe-counter, vitamins and herbs.
FOR OFFICE USE ONLY
COMMENTS / NOTES
Date_____________
Name:_____________________ DOB_____________
Financial Information:
Please provide the names of all individuals living in the household and indicate the type and amount of gross monthly
income received by each household member. Verification of gross monthly income is required by all household members
receiving income. Please provide copies of the most recent statement from pensions, retirement, social security, social
security disability, unemployment, worker’s compensation, alimony/child support, food and nutrition services, aid for
families with dependent children, fuel assistance, housing assistance, and any other form of income. Copies of the most
recent monthly pay vouchers are required from all household members who are employed.
Gross Monthly Income (Income before any deductions are subtracted)
Household
Member 1
Household
Member 2
Household
Member 3
Household
Member 4
Household
Member 5
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Social Security
$
$
$
$
$
$
Supplement Social
Security Income
Social Security
Disability
Unemployment
Compensation
Worker’s Compensation
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Alimony/Child Support
Food and Nutrition
Services
Aid for Families with
Dependent Children
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Fuel Assistance
$
$
$
$
$
$
Housing Assistance
Retirement Benefits
Other Income (i.e.
rental, investments):
Total
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Patient
Name
Age
Relationship to Patient
Gross Monthly
Salary/Wages
(Before Deductions)
Pension
VA Pension
Date_____________
Name:_____________________ DOB_____________
Asset Information:
Please provide names of all household members and indicate the types of asset that each household member has. Copies
of current statements are required from each household member to verify account balances for each asset selected below.
Household
Member 1
Household
Member 2
Household
Member 3
Household
Member 4
Household
Member 5
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
CDs
$
$
$
$
$
$
Annuities
$
$
$
$
$
$
Other
Total
$
$
$
$
$
$
$
$
$
$
$
$
Patient
Name
Age
Relationship to Patient
Checking
Savings
Stocks/Bonds
Please list any other household members that were not included above. Please include their name, age,
relationship, income and any assets that they may have. Copies of income and asset statements are
required for these family members as well.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
We require a copy of the previous year’s tax return from each member of your household who filed. A
signed 4506-T is required from each household member who did not file taxes.
Zero Income: If you have no income, a letter stating that you have no income along with the amount
of support provided you monthly for rent, food, utilities and medications must be provided. The letter
needs to be dated and signed by the individual(s) who provides your support.
I / We state that the above financial and demographic information is correct as of this date, _______________.
Thank you,
________________________________ Date__________________________
(Patient signature)