Follow the steps to complete the medication review form effectively.

1. Click ‘Get Form’ button to obtain the form and access it for filling.
2. Enter patient information in the designated fields. This includes the patient’s full name, Medicaid ID number, and date of birth.
3. Provide the primary care physician's details including their name, phone number, and fax number.
4. List the pharmacy name along with their contact phone number and fax number.
5. Indicate if the patient has any known allergies to medications. If yes, please provide details in the space provided.
6. Complete the medication profile section thoroughly. Include all medications the patient is taking, specifying the start date, medication name, strength, quantity, regimen, purpose of use, prescribing physician, precautions, and stop date for each medication. You may attach additional pages if necessary.
7. Fill out the medication review communication section to outline any prescription issues identified during the review.
8. Document the recommended plans of action for any identified medication-related issues, including options for cost-effective recommendations.
9. Sign and date the review, and ensure that both the pharmacist and primary care physician’s signatures are included.
10. Once completed, save your changes, and you may choose to download, print, or share the form as needed.

Complete your Focused Risk Management Program (FORM) Medication Review online today.