Conducting CMRs with the standardized format and Fulfillment burden

Medication Therapy Management Program Improvements - Standardized Format (CMS-10396)

MTM Program Standardized Format (English & Spanish) (rev OSORA PRA)

Conducting CMRs with the standardized format and Fulfillment burden

OMB: 0938-1154

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1154 can be found here:

Document [docx]

Download: docx | pdf

Medication Therapy Management Program Standardized Format – English

Form CMS-10396

Shape1

< 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 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 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 <insert contact information for MTM provider, phone number, days/times, TTY, etc. >. < 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. >

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: 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:


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. >.

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. Keep this list up-to-date with: prescription medications over the counter drugs herbals vitamins 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 intended medical use >	Prescriber: < Insert prescriber’s name >
< 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 estimated by Plan or entered based upon beneficiary-reported data, or leave blank for beneficiary to enter start date >	Date I stopped using it: < Leave blank for beneficiary to enter stop date >
Why I stopped using it: < Leave blank for beneficiary’s notes >

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:

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.

Medication Therapy Management Program Standardized Format – Spanish

Form CMS-10396 (07/14)

FORMATO ESTANDARIZADO PARA EL PROGRAMA DE CONTROL DE LA TERAPIA DE MEDICAMENTOS DE LA PARTE D DE MEDICARE

Shape9

< Espacio adicional para uso optativo del plan/proveedor para códigos de barra, número de referencia del documento, título o número del caso >

< Fecha >

< Dirección >

< Saludo >:

Le agradezco por el tiempo que me dedicó el < ingrese la fecha > para hablar sobre su salud y sus medicamentos. El Programa de Control de la Terapia de Medicamentos de Medicare (MTM en inglés) le ayuda a entender sus medicamentos y a utilizarlos con seguridad.

Esta carta incluye un plan de acción (Plan de medicamentos) y una lista de los medicamentos (Lista personal de medicamentos). El plan de acción le indica los pasos que debe seguir para obtener los mejores resultados de su terapia de medicamentos. La lista de medicamentos le ayudará a monitorear sus medicamentos y le explicará cómo tomarlos correctamente.

Cuando hable con sus médicos, farmacéuticos y otros profesionales de la salud de su equipo de atención médica, tenga a mano su plan de acción y la lista de medicamentos.
Pídale a sus médicos, farmacéuticos y otros profesionales de la salud que actualicen el plan de acción y la lista de medicamentos en cada visita.
Si tiene que ir a la sala de emergencia o al hospital lleve su lista de medicamentos.
Entréguele a sus familiares y a la persona que lo cuida una copia del plan de acción y de la lista de medicamentos.

Si tiene preguntas sobre esta carta o los documentos adjuntos, llame a <ingrese la información de contacto del proveedor del MTM, el número de teléfono, fechas/horas, TTY, etc. >. <Espero/amos> trabajar con usted, sus médicos, y otros proveedores de atención médica a través de < nombre del plan de la Parte D > del programa MTM, para mantenerlo saludable.

< Ingrese el párrafo de despedida, la firma del proveedor del programa MTM, el nombre, título, adjuntos, etc. >

Plan de Acción Para < Nombre del beneficiario, fecha de nacimiento: mes/día/año >

Este plan de acción le permitirá obtener los mejores resultados si:

Lee “Acerca de lo que hablamos.”
Sigue los pasos mencionados en “Lo que debo hacer”.
Anota “Lo que hice y cuándo lo hice.”
Anota “Mi plan de seguimiento” y “Las preguntas que quiero hacer.”

Cuando hable con sus médicos, farmacéuticos y otros profesionales de la salud de su equipo de atención médica, tenga a mano su plan de acción. Compártalo también con sus familiares y con la persona que lo cuida.

Preparado El: < Fecha >

Acerca de lo que hablamos:

< Describa el tema tratado >

Lo que debo hacer:

< Las actividades recomendadas al beneficiario >