Patient Enrollment Packet

ALL patients must complete and sign. Keep these on file. These forms are REQUIRED for each patient enrolled in the Medicaid pilot.

• Patient Enrollment Packet  (New!  5/1/12)

          Mail Merge all required information into forms - AutoComplete, then print.

          Individual forms contained in the above are listed below and can be downloaded separately.

• Patient Enrollment and Medical Release
• Study Disclosure / Policies and Procedures 
• Exercise Release  
• Protected Health Information Release  
• Letter to Physician RE: Patient Enrollment  
• Lab Values Request to Physician's Office (Fax Form)   
• Patient History Questionnaire

Supplemental Forms / Tools / Documents

• Health Attitudes (Adherence Indicator Spreadsheet Tool)
• Health Attitudes Descriptive Key
• Timeline for Pharmacist / Patients
• MTM Care Process
• Pharmacy MTM Checklist
• Common Lab Values
• MTM Training Handbook (J. John & T. Siluk Edition)
• Personal Medication Record (PMR)
• Medication Action Plan (MAP)
• Eating Smart

Practice Resources

• Hypertension - JNC-7
• Diabetes
  • ADA Guidelines
  • Texas Diabetes Council Algorithms and Guidelines 
• Dyslipidemia - ATP-III