Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)

Visual Aid #3 – Personal Medication List Mockup
Dr. Jane Doe
1500 Main Street
Anytown, MD 21201
PERSONAL MEDICATION LIST FOR Mr. John Smith, DOB: 07/04/1940
This medication list was made for you after we talked. We also used information
from Medicare Part D claims data.
 Use blank rows to add new
Keep this list up-to-date with:
medications. Then fill in the dates
 prescription medications
you started using them.
 over the counter drugs
 Cross out medications when you no
 herbals
longer use them. Then write the date
and why you stopped using them.
 vitamins
 Ask your doctors, pharmacists, and
 minerals
other healthcare providers in your
care team to update this list at every visit.
If you go to the hospital or emergency room, take this list with you. Share this
with your family or caregivers too.

DATE PREPARED: 01/14/2013
Allergies or side effects: Penicillin - hives and difficulty swallowing

Medication: Simvastatin 20 mg tablet
How I use it: Take one tablet (20 mg) by mouth every night
Why I use it: High Cholesterol
Prescriber: Dr. Joe Anne
Goals:
 LDL (Low Density Lipoproteins) < 100 mg/dL
 HDL (High Density Lipoproteins) > 40 mg/dL
Date I started using it: January 2009
Why I stopped using it:

Date I stopped using it:

Medication: Glipizide XL (Glucotrol XL) 5 mg tablet
How I use it: Take one tablet (5mg) by mouth once daily
Why I use it: Type 2 Diabetes
Prescriber: Dr. Joe Anne
Date I started using it: June 2010
Date I stopped using it:
Why I stopped using it:

Form CMS-10396 (07/14)

Form Approved OMB No. 0938-1154

Page 1 of 2

Visual Aid #3 – Personal Medication List Mockup
PERSONAL MEDICATION LIST FOR Mr. John Smith, DOB: 07/04/1940
(Continued)
Medication: Albuterol Sulfate Inhalation Solution (Ventolin HFA)
How I use it: Use 2 puffs every 6 hours as needed for shortness of breath
Why I use it: Breathing
Prescriber: Dr. Joe Anne
Reminder:
 Refer to leaflet on proper technique.
 Keep with you at all times – “rescue inhaler.”
Date I started using it: Early 2011
Date I stopped using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Notes:
Date I started using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Notes:
Date I started using it:
Why I stopped using it:

Prescriber:
Date I stopped using it:

Prescriber:
Date I stopped using it:

Other Information:

If you have any questions about your medication list, call Dr. Jane Doe at 1-800222-3333 between the hours of 9am and 5pm, Monday through Friday.

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 0938-1154. The time required to complete this information collection is
estimated to average 40 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed,
and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850

Form CMS-10396 (07/14)

Form Approved OMB No. 0938-1154

Page 2 of 2