Form CMS-10396 Medication Therapy Management Program Standardized Forma

Attachment B: Mock-up with Proposed Revisions

Medication Therapy Management Program
Standardized Format – English

< MTM PROVIDER HEADER or
OPTIONAL LOGO >

< MTM PROVIDER HEADER or
OPTIONAL 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 understand your medications and use them safely.
This letter includes 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 healthcare providers in your care team.
• Ask your doctors, pharmacists, and other healthcare providers to update the
action plan and medication list 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, your doctors, and other healthcare
providers 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-10396 (01/12)

Form Approved OMB No. 0938-1154

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< MTM PROVIDER HEADER or
OPTIONAL LOGO >

< MTM PROVIDER HEADER or
OPTIONAL 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 in your care team. 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-10396 (01/12)

Form Approved OMB No. 0938-1154

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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-10396 (01/12)

Form Approved OMB No. 0938-1154

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< MTM PROVIDER HEADER or
OPTIONAL LOGO >

< MTM PROVIDER HEADER or
OPTIONAL 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
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
vitamins
and why you stopped using them.
minerals
• Ask your doctors, pharmacists, and
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: < 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-10396 (01/12)

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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-10396 (01/12)

Form Approved OMB No. 0938-1154

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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 0938-1154. 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 (01/12)

Form Approved OMB No. 0938-1154

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