Get Iehp Medication Therapy Management Mtm Program

The IEHP Medication Therapy Management (MTM) Program provides essential pharmaceutical support for patients with Autism Spectrum Disorder (ASD). This guide will assist you in accurately completing the MTM referral form online to ensure that your patients receive the best possible care.

Follow the steps to fill out the MTM referral form online.

1. Click ‘Get Form’ button to obtain the referral form and open it for completion.
2. Begin by checking any applicable criteria that the patient meets, such as taking four or more chronic medications, observed non-compliance, or being on medications related to severe ASD.
3. Provide the patient's personal information, including their name, guardian’s name, address, city, state, date of birth (DOB), and phone number.
4. Document the patient's medical history, highlighting any specifics regarding seizure events or other developmental conditions.
5. List any known allergies and current medications with their strengths and directions. Include details on previous medications as well.
6. Record the patient's height and weight, and calculate the BMI, providing this information accurately.
7. Indicate the patient’s gender and answer health-related questions, such as smoking status, pregnancy, substance abuse history, and alcohol consumption.
8. Confirm whether the patient’s immunizations are up to date. If any are missing, specify which ones were not given.
9. Provide a clear reason for the referral, ensuring it outlines the specific needs of the patient.
10. Fill in your name as the referring party, along with your phone number and signature. Finally, include the date of completion.
11. Once finished, save the completed form, and then fax it to (909) 890-5763. For any questions, please call (909) 890-2054.

Complete the referral form online to ensure your patients receive timely support.