Medication Therapy Management (MTM) Referral Form Fax Number: (866) 771-0117 [email protected] Patient Name: Patient DOB: Referring Provider: Name: Provider Phone Number: Provider Fax Number: Patient Contact Information (best phone number to call): Phone Number: Initial Screening Questions: The patient has the following diagnoses (check all that apply): Asthma Heart Failure or CHF COPD Hypertension Diabetes Depression Dyslipidemia PTSD/Bipolar Disorder/Schizophrenia/ASD Renal Disease Nausea/Vomiting Arthritis Substance/Drug Abuse Uncontrolled Pain GERD Other: Number of Chronic Medications: Primary Reasons for Referral (Check all that apply): Patient is non-adherent to prescribed medications Patient does not understand why they are taking their medications Patient has unresolved symptoms related to their chronic conditions Patient is concerned about side effects of their medications Patient feels he/she is taking too many medications Provider MTM Referral Form_REVISED_v3_DATE_11Nov2014 Medication Therapy Management (MTM) Referral Form Fax Number: (866) 771-0117 [email protected] Brief Description of Outstanding Concerns Any Materials That Should Referenced Prior to the Session? (Please include document locations and dates.) Office Contact: Date: Provider MTM Referral Form_REVISED_v3_DATE_11Nov2014
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