Form CMS-10396 MEDICATION THERAPY MANAGEMENT PROGRAM STANDARDIZED FORMA

MEDICARE PART D
MEDICATION THERAPY MANAGEMENT PROGRAM
STANDARDIZED FORMAT

Effective as of January 1, 2013

Form CMS-XXXX (MM/YY)

Form Approved OMB No. 0938-NEW

< MTM PROVIDER HEADER >

< PLAN LOGO >

< Additional space for
optional plan/provider use,
such as barcodes, document
reference numbers, beneficiary
identifiers, case numbers or
title of document>

< Insert date >
< Insert inside address >

< Insert salutation >:
Thank you for talking with me on < insert date of service > about your health and
medications. Medicare’s MTM (Medication Therapy Management) program helps
you make sure that your medications are working.
Along with this letter are an action plan (Medication Action Plan) and a medication
list (Personal Medication List). The action plan has steps you should take to
help you get the best results from your medications. The medication list will
help you keep track of your medications and how to use them the right way.
Have your action plan and medication list with you when you talk with your
doctors, pharmacists, and other health care providers.
Ask your doctors, pharmacists, and other healthcare providers to update
them at every visit.
Take your medication list with you if you go to the hospital or emergency
room.
Give a copy of the action plan and medication list to your family or
caregivers.
If you want to talk about this letter or any of the papers with it, please call . <
I/We > look forward to working with you and your doctors to help you stay healthy
through the < insert name of Part D Plan > MTM program.
< Insert closing, MTM provider signature, name, title, enclosure notations, etc. >

Form CMS-XXXX (MM/YY)

Form Approved OMB No. 0938-NEW

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< MTM PROVIDER HEADER >

< PLAN LOGO >

MEDICATION ACTION PLAN FOR < Insert Member’s name, DOB: mm/dd/yyyy >
This action plan will help you get the best results from your medications if you:
1.
2.
3.
4.

Read “What we talked about.”
Take the steps listed in the “What I need to do” boxes.
Fill in “What I did and when I did it.”
Fill in “My follow-up plan” and “Questions I want to ask.”

Have this action plan with you when you talk with your doctors, pharmacists, and
other healthcare providers. Share this with your family or caregivers too.

DATE PREPARED: < Insert date >
What we talked about:
< Insert description of topic >
What I need to do:
< Insert recommendations for
beneficiary activities >

What I did and when I did it:
< Leave blank for beneficiary’s notes >

What we talked about:

What I need to do:

What I did and when I did it:

What we talked about:

What I need to do:

What I did and when I did it:

Form CMS-XXXX (MM/YY)

Form Approved OMB No. 0938-NEW

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What we talked about:

What I need to do:

What I did and when I did it:

What we talked about:

What I need to do:

What I did and when I did it:

My follow-up plan (add notes about next steps):
< Leave blank for beneficiary’s notes >

Questions I want to ask (include topics about medications or therapy):
< Leave blank for beneficiary’s notes >

If you have any questions about your action plan, call < insert MTM provider
contact information, phone number, days/times, etc. >.

Form CMS-XXXX (MM/YY)

Form Approved OMB No. 0938-NEW

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< MTM PROVIDER HEADER >

< PLAN LOGO >

PERSONAL MEDICATION LIST FOR < Insert Member’s name, DOB: mm/dd/yyyy >
This medication list was made for you after we talked. We also used information
from < insert sources of information >.
Use blank rows to add new
medications. Then fill in the dates
you started using them.
Cross out medications when you no
longer use them. Then write the date
and why you stopped using them.
Ask your doctors, pharmacists, and
other healthcare providers to update
this list at every visit.

Keep this list up-to-date with:
prescription medications
over the counter drugs
herbals
vitamins
minerals

If you go to the hospital or emergency room, take this list with you. Share this
with your family or caregivers too.

DATE PREPARED: < Insert date >
Allergies or side effects: < Insert beneficiary’s allergies and adverse drug
reactions including the medications and their effects >
Medication: < Insert generic name and brand name, strength, and dosage form
for current/active medications. >
How I use it: < Insert regimen, including strength, dose and frequency (e.g., 1
tablet (20 mg) by mouth daily), use of related devices and supplemental
instructions as appropriate >
Why I use it: < Insert indication or
Prescriber: < Insert prescriber’s name
intended medical use >
>
< Insert other title(s) or delete this field >: < Use for optional product-related
information, such as additional instructions, product image/identifiers, goals of
therapy, pharmacy, etc., and change field title accordingly. This field may be
expanded or divided. Delete this field if not used. >
Date I started using it: < May be
Date I stopped using it: < Leave blank
estimated by Plan or entered based
for beneficiary to enter stop date >
upon beneficiary-reported data, or leave
blank for beneficiary to enter start date
>
Why I stopped using it: < Leave blank for beneficiary’s notes >

Form CMS-XXXX (MM/YY)

Form Approved OMB No. 0938-NEW

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PERSONAL MEDICATION LIST FOR < Insert Member’s name, DOB: mm/dd/yyyy >
(Continued)
Medication:
How I use it:
Why I use it:
Prescriber:
< Insert other title(s) or delete this field >:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Prescriber:
< Insert other title(s) or delete this field >:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Prescriber:
< Insert other title(s) or delete this field >:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Prescriber:
< Insert other title(s) or delete this field >:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Prescriber:
< Insert other title(s) or delete this field >:
Date I started using it:
Date I stopped using it:
Why I stopped using it:

Form CMS-XXXX (MM/YY)

Form Approved OMB No. 0938-NEW

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PERSONAL MEDICATION LIST FOR < Insert Member’s name, DOB: mm/dd/yyyy >
(Continued)
Medication:
How I use it:
Why I use it:
Prescriber:
< Insert other title(s) or delete this field >:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Prescriber:
< Insert other title(s) or delete this field >:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Prescriber:
< Insert other title(s) or delete this field >:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
Other Information:

If you have any questions about your medication list, call < insert MTM provider
contact information, phone numbers, days/times, etc. >.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB number for this information collection is 0938-XXXX. The time required to complete this information collection is
estimated to average 37.76 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed,
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improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Form CMS-XXXX (MM/YY)

Form Approved OMB No. 0938-NEW

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