PLEASE FILL OUT & RETURN 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 that this information may be shared with the clinical certified geriatric pharmacist (PharmD, CGP) at IntegriCare Clinical Associates who will review my application and look for any problems I might be experiencing. Based on the evaluation of all my prescription drugs, over-the-counter medications, and dietary supplements, the pharmacist will provide me with recommendations for changes in my medications that need to be discussed with my physician. I agree that my MTM Medication Review may be sent to my physician(s) or, if I prefer, personally delivered. ** I acknowledge that I have been provided with a copy of the Nevada Department of Health and Human Services, Nevada Aging and Disability Services Division s Notice of Privacy Practices. ** I agree to discuss the recommendations made by the pharmacist with my physician before I change or stop taking medications.** I authorize the release of the MTM Information Form to the Sanford Center for Aging (SCA) at the University of Nevada, Reno, relevant employees, and agents. 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 MTM Program Director, Greta Engelbrecht at 775-784-1612. Signature Date: _ Print Name Telephone Number: ( ) E-mail: Alternate Telephone Number: ( ) Other Representative: For Office Use Only: 1 st Contact Date: CGP Telephone Consultation Date/Time: Notes: This program is sponsored by the Nevada Aging and Disability Services Division and The Marion G. Thompson Charitable Trust
Medication Therapy Management - Information Form Date: / / INFORMATION ABOUT YOU Name: Street Address: Apt: City: NV Zip Code: Best Time of Day to Call You: Date of Birth: / / Age: Gender: Male Female Are you Hispanic or Latino? Yes No What is your Primary Language?: Race / Ethnicity you most closely identify with: (Mark all that apply) American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White/Caucasian Other, specify: What is your MONTHLY NET household income? $ IF your monthly NET income is OVER $1,771 for a single, $2,391 for a couple, a Fee for Service may apply. To determine if a Fee for Service applies to you, please contact Greta Engelbrecht at (775) 784-1612 Do you live alone? Yes No IF NO, how many other people 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? Yes No Do you have Medicare Part D? Yes No If YES, what is the name of your Prescription Drug Plan (PDP)?: AARP MedicareRx Humana Senior Care Plus Senior Dimensions Other, specify: PHYSICIAN INFORMATION Name of Your Primary Care Physician**: Telephone number: ( ) Fax number: ( ) Date of LAST routine Primary Care Physician appointment (mm/dd/yyyy) / / Date of NEXT routine Primary Care Physician appointment (mm/dd/yyyy) / / *** A copy of your medication review will be sent to your primary care physician*** List other physicians OR specialists who have prescribed you medications (add additional pages if needed). You will be provided with extra copies of the MTM report to give to your specialists. Name of Your Specialist Physician(s) Specialty 2
PERSONAL HEALTH INFORMATION How would you rate your overall health?: Excellent Very Good Good Fair Poor Are you limited in any way due to (Check all that apply): Illness Injury Mental/Emotional issues Not Applicable Other Are you disabled? Yes No If YES, what type of disability do you have? Developmental Neurological Sensory Other, specify: Mental/Emotional Physical Traumatic Brain Injury Do you require the use of special equipment? (Ex: cane, wheelchair, special bed or telephone). No Yes Please Specify: Do you need assistance with (Mark all that apply): None I can perform these activities Eating Toileting Bathing Preparing Meals Transferring In or Out Taking Medications of Bed and/or Chair Managing Money Dressing Shopping Light Housework Heavy Housework Using the Telephone Using Transportation Service Are you Frail? Yes No Are you Homebound? Yes No Do you have a Caregiver? Yes 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 # Please provide the reasons you needed emergency care: (Mark all that apply) Heart attack Congestive Heart Failure Cardiac Dysrhythmia/Arrhythmia Stroke Dizziness Fall Abdominal Problems Confusion Dehydration Problems with Medication Fever Syncope Not Applicable Not Applicable Injury (Specify): Infection (Specify): Other (Specify): In the past 3 months, have you fallen? Yes No If YES, how many times have you fallen? Enter # Don t Know / Not Sure Not Applicable Did any of these falls cause an injury? Yes No Not Applicable If YES, how many of these falls caused an injury? Enter # Not Applicable During the past 12 months, were you admitted to a nursing home? Yes No 3
PERSONAL HEALTH INFORMATION (continued) Have you ever been told by a doctor or other health care professional that you have any of the following medical diagnoses or health conditions? (Check all that apply): High Blood Pressure Stroke Heart Attack Atrial Fibrillation Congestive Heart Failure COPD / Asthma High Cholesterol Diabetes Depression Neuropathy Alzheimer s disease Dementia Arthritis Osteoporosis Parkinson s disease Hyper/Hypothyroidism Cancer Specify: Gastrointestinal Issues Specify: Other Specify: Has a doctor or other health care professional ever told you to (Check all that apply): Gain/Lose Weight Stop Drinking Alcohol Stop Smoking Tobacco None of these Do you have concerns about your appetite? No Yes (Specify): Have you had any lab work done in the past 6 months? No Yes If YES please specify: Do you have the lab results? Yes No Have you had any X-rays done in the past 6 months? No Yes If YES please specify: COMMENTS: Please list anything else that you feel the pharmacist should know about your health, the medications you are taking, or side effects you are experiencing. You can list side effects you experience, e.g. confusion, dizziness, fatigue or muscle weakness, dry mouth, constipation, urinary retention. You could ask specific questions can any of my drugs increase my risk for falls, cause memory problems, nausea or depression? 4
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 Strength Number of Times Day Side Effects/ Adverse Reactions/Problems when taken Started When? Example: Ibuprofen 400 mg Twice Daily Side effect: stomach ache June 2006 5
MEDICATION USE (continued) Do you have any medication allergies? Yes No If YES, please list the medications: Are you currently taking any expired drugs? Yes No 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 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 6
MEDICATION KNOWLEDGE / COMPLIANCE (continued) How do you obtain medications? (Mark all that apply) Self-transport to pharmacy Caregiver obtains Doctors samples Mail order to pharmacy Other (Specify): Do you go to multiple pharmacies to buy your prescription medications? No Yes If YES: How many pharmacies do you go to? Enter # Why do you go to multiple pharmacies to buy your prescription medications? Do you have trouble affording prescribed medications? No Yes If YES, which medication(s)? Do you have someone who manages your medications for you? No Yes If YES: Name: Relationship to you: Ph #: ( ) How do you remember to take your medications? (Mark all that apply) Caregiver Administers Pill Box or other organizer Calendar Directions on Prescription Label When medications are missed, what is the cause? (Mark all that apply) Other (Specify): Never Missed Don t feel good when taken Expensive Forget Other Specify): How long did it take you to complete this form? MTM FOLLOW-UP CALL Please inform the MTM Program (775-784-1612) of the date of your next regularly scheduled doctor s appointment AFTER you receive the clinical certified geriatric pharmacist s Medication Review. Based on this date the MTM program will conduct a Follow-up call to ask you a few questions regarding the review, your health status and if any changes were made to your drug regimen. HOW TO SUBMIT THIS FORM If you have any questions concerning this application, please contact Greta Engelbrecht or Whitney Wilding at (775) 784-1612. Please SIGN the Consent Form (keep the copy for your records). Return the MTM Information Form in the pre-paid envelope provided or MAIL to Medication Therapy Management Program, Sanford Center for Aging / 146, University of Nevada, Reno 89557-0146. The MTM Information Form can also be FAXED to (775) 784-6721 We also accept voluntary, confidential contributions. If you would like to contribute to this program or receive information concerning the Sanford Center for Aging s donation policy, please contact Greta Engelbrecht, at (775) 784-6721 or e-mail at gengelbrecht@unr.edu. Thank you! 7