PROPOSED FORM - For Review
MEDICATION LIST
Section 4: Medical (Annual Review Required)
Member Name:
Date of Birth:
MassHealth ID:
Date Updated:
Primary Care Provider:
PCP Phone:
Pharmacy:
Pharmacy Phone:
ALLERGIES / ADVERSE REACTIONS
Medication Name
Dose
Frequency
Route
Reason / Diagnosis
Prescriber
Start Date
Active?
Over-the-Counter Medications / Supplements / Vitamins:
Name
Dose
Frequency
Reason
Member/Representative Signature
Date
RN Signature
Date
Review History:
This form must be reviewed and updated at least annually, or whenever medications change.
Review Date
Reviewed By
Changes Made