PLEASE FILL OUT, SIGN & SUBMIT THIS FORM
MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM CONSENT
and AUTHORIZATION for RELEASE of INFORMATION
I agree to participate in the Medication Therapy Management (MTM) Program. I will complete the attached MTM
Information Form listing all my medications and supplements and agree to review this information with a Clinical
Pharmacist who will review my medication form and look for any problems I might be experiencing. Based on the
evaluation of all my prescription drugs, over-the-counter medications, vitamins and herbal supplements, the
pharmacist will provide a set of recommendations for changes in my medication regimen. A Patient Care
Representative (PCR) will contact me to schedule the telephone consultation with the Clinical Pharmacist.
** I acknowledge that I have been provided with a copy of the MediFixx MTM Pharmacy’s Notice of Privacy
Practices.
** I agree to discuss the recommendations made by the pharmacist with my doctor before I change or stop taking
medications.**
I authorize the release of the MTM Information Form to MediFixx MTM Pharmacy. This authorization
constitutes a full and complete release from any liability from disclosure of such information. A photocopy of this form
shall be as valid as the original.
If I have any questions, I may contact the Pharmacy Director, Christina Wachuku at 772-777-1729.
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Signature
Date
Print Name
Address / City / State / Zip
(
)
Phone Number
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Medication Therapy Management - Information Form
Date:
/
/
INFORMATION ABOUT YOU
Name:
Street
Apartment:
City:
Telephone Number: (_
Date of Birth:
)
/
,
/
Yes
FL
Zip
Code:
Best Time of Day to Call You:
Age:
Are you Hispanic or Latino?
Address:
Gender:
No
Male
Female
What is your Primary Language?:
Race / Ethnicity you most closely identify with: (Mark all that apply)
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Asian
White/Caucasian
Black/African American
Other, specify:
Do you live alone?
Yes
No
IF NO, how many family members live in your household?
How did you hear about this program?
INSURANCE INFORMATION
Do you have private insurance?
Yes
No
If YES, what plan?
Do you have Medicare?
Yes
No
Medicaid?
Do you have Medicare Part D?
Yes
No
Yes
No
If YES, what is the name of your Prescription Drug Plan(PDP)?:
AARP MedicareRx
Other, specify:
Humana
Senior Care Plus
Senior Dimensions
PHYSICIAN INFORMATION (continued on the next page)
Name of Your Primary Care Physician**:
Address of Your Primary Care Physician:
Telephone number: ( )
Fax number: (
)
last routine Primary Care Physician appointment (mm/dd/yyyy)
Date of NEXT routine Primary Care Physician appointment (mm/dd/yyyy)
Date of
/
/
/
/
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** A copy of your medication review will be sent to your primary care physician.
List other physicians OR specialists who have prescribed you medications (please add additional pages if needed).
You will be provided with extra copies of the MTM report to give to your specialists.
NAME
Telephone number
FAX number
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
HEALTH INFORMATION
How would you rate your overall health?:
Excellent
Very Good
Good
Are you limited in any way due to (Mark all that apply):
Illness
Injury
Mental or Emotional issues
Fair
Other:
Poor
Not Applicable
Are you disabled?
Yes
No
If YES, what type of disability do you have?
Do you require the use of special equipment? (Ex: cane, walker, wheelchair, special bed, or special telephone).
Yes
No
Do you need assistance with (Mark all that apply):
Eating
Bathing
Transferring In or Out of Bed and/or Chair
Dressing
Toileting
Preparing Meals
Taking Medications
Managing Money
Shopping
Light Housework
Heavy Housework
Using the Telephone
Using Transportation
Services
None – I can perform these activities
Are you Frail?
Are you Homebound?
Do you have a Caregiver?
Yes
Yes
Yes
No
No
No
Are you a Caregiver?
Yes
No
IF you are a Caregiver, who do you care for?
Spouse
Child, Age 0-18
Adult Child
Parent
Family Member
Other
During the past 12 months, were you hospitalized or did you go to an emergency room, urgent care, or see your
physician for an unplanned visit (emergency)?
Yes
No
If YES, how many times did you need emergency care? Enter #
Not Applicable
Please provide the reasons you needed emergency care: (Mark all that apply)
Not Applicable
Heart attack
Dizziness
Problems with Medications
Congestive Heart Failure
Fall
Dehydration
Cardiac Dysrhythmia/Arrhythmia
Abdominal Problems
Fever
Stroke
Confusion
Syncope
Injury (Specify):
Infection (Specify):
Other (Specify):
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In the past 3 months, have you fallen?
Yes
If YES, how many times have you fallen? Enter #
Did any of these falls cause an injury?
Yes
If YES, how many of these falls caused an injury?
No
Don’t Know / Not Sure
No
Enter #
During the past 12 months, were you admitted to a nursing home?
Yes
Not Applicable
Not Applicable
Not Applicable
No
Have you ever been told by a doctor or other health professional that you have any of the following medical
diagnoses or health conditions? (Mark all that apply)
High Blood Pressure
Diabetes Depression
Parkinson’s disease
Stroke
Neuropathy
Hyper/Hypothyroidism
Alzheimer’s Disease
Heart Attack
Cancer (Specify):
Atrial Fibrillation
Gastrointestinal Issues (Specify):
Congestive Heart Failure
COPD / Asthma
High Cholesterol
Dementia
Arthritis
Osteoporosis
Have you had any lab work done in the past 6 months?
Other (Specify):
Yes (Specify):
No
Do you have the lab results?
Have you had any X-rays done in the past 6 months?
Yes
No
Yes (Specify):
No
What types of health issues are you currently concerned about?
Comments: (Please list anything that you feel is important to know about your health or your medications)
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MEDICATION USE
Please list all current prescription medications that are taken routinely, including medications that are taken on an “as
needed” basis. Also include over-the-counter medications, vitamins, herbal supplements, and samples. Please use a
separate sheet of paper if needed.
Medication Name
and Strength
Amount/
Dose
Taken
How
Often?
Example:
Metformin/ 500mg
2 tablets
Twice
Daily
Side Effects/
Adverse
Reactions
when taken
Diarrhea
Reason for
Use
Diabetes
Control
Prescribing
Physician
Started
When?
Dr. John
Matt
wDoe
July
2014
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MEDICATION USE (continued)
Do you have any medication allergies?
Yes
No
Yes
No
If YES, please list the medications:
Are you currently taking any expired drugs?
If YES, please list the expired drugs you continue to take:
Are there recent changes in medications?
Yes
No
If YES, please list any recent changes in medications:
MEDICATION KNOWLEDGE / COMPLIANCE
How knowledgeable are you about the medications you are taking? (Mark 1 Box per Question)
Very Knowledgeable
Knowledgeable
Somewhat Knowledgeable Not
Knowledgeable
How knowledgeable are you about the possible risk factors associated with your medications?
Very Knowledgeable
Knowledgeable
Somewhat Knowledgeable Not
Knowledgeable
How confident are you that the medications you are taking are appropriate for your current health
condition(s)?
Very Confident
Confident
Somewhat Confident Not
Confident
How comfortable are you speaking to your physician(s) about the medications you are taking?
Very Comfortable Comfortable
Somewhat Comfortable
Not Comfortable
Do you understand what each of your medications is for?
Yes
No
Unsure
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MEDICATION KNOWLEDGE / COMPLIANCE (continued)
Do you take each medication as directed by your physician (Ex: with food, on an empty stomach, with a full glass of
water, etc.)?
Yes
No
How do you obtain medications? (Mark all that apply)
Self-transport to pharmacy
Caregiver obtains
Mail order to pharmacy
Other (Specify):
Doctors samples
Do you go to multiple pharmacies to buy your prescription medications?
Yes
If YES: How many pharmacies do you go to? Enter #
No
Not Applicable
Why do you go to multiple pharmacies to buy your prescription medications?
Do you have trouble affording prescribed medications?
Yes
If YES, which medication(s)?
No
Not applicable
Do you have someone who manages your medications for you?
Yes
No
If YES:
Name:
Ph #: (
)
-
_
Their relationship to you:
How do you remember to take your medications? (Mark all that apply)
Caregiver Administers
Pill Box or other organizer
Directions on Prescription
Label
Other (Specify):
Calendar
When medications are missed, what is the cause? (Mark all that apply)
Don’t feel good when taken
Expensive
Other (Specify):
Never Missed
Forget
How long did it take you to complete this form?
The Form Continues on the Next Page
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HOW TO SUBMIT THIS FORM
 If you have any questions concerning this application, please contact Christina Wachuku at (772) 7771729.
 Please SIGN the Consent Form / MTM Information Form and return mail to MediFixx MTM Pharmacy, LLC,
2601 SW Gallery Circle, Palm City, FL, 34990.
Thank You!
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