Document a comprehensive medication review (CMR) and print the patient summary in the CMS Medicare Part D MTM Standardized Format: cover letter, Recommended To-Do List, and Medication List, in English or Spanish. A pharmacist worksheet sorts medication-related problems by indication, effectiveness, safety, and adherence.
Everything stays on this device. Nothing you type here is sent to ClinDose or anyone else.
Off: closing or reloading the page discards your work.
Review details
Language changes the fixed template text. What you type prints as typed.
Review done with a caregiver or representative
For a beneficiary who can't take part because of cognitive impairment. Adds the CMS note to the cover letter and, if you mail it to the representative, a "c/o" line.
You (signs the cover letter)
Medications
Abbreviations become plain words ("1 tab po bid" becomes "1 tablet by mouth twice a day"). Include prescription drugs, over-the-counter drugs, herbals, vitamins, and samples.
Optional kidney check: to see the label's kidney dosing row for each drug.
Allergies and side effects
Recommended To-Do List
The patient's action plan. Put the most important topic first. If there's nothing new to do, add a reinforcing statement (for example, keep taking your medications as you do now).
Safe disposal page
Still to add: member name, date of birth, CMR date, your name, who to call, contact information, medications, a to-do topic. Missing fields are highlighted on the preview and print blank.
Letter-size, 14-point type, in CMS order. Each document restarts its page numbers. If the Medication List doesn't print in landscape, print it on its own and choose landscape.
letter date
member name address city, state, ZIP
Dear ,member name
Thank you for talking with me on , about your health and medications. As a follow-up to our conversation, I have included two documents: CMR date
Your Recommended To-Do List has steps you should take to get the best results from your medications.
Your Medication List will help you keep track of your medications and how to take them.
If you want to talk about these documents, please call at . who to call and how
I look forward to working with you and your doctors to make sure your medications work well for you.
Sincerely,
your name your title, plan, pharmacy, or organization
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
Recommended To-Do List for member name, DOB: DOB
Recommended To-Do List
Prepared on: CMR date
You can get the best results from your medications by completing the items on this “To-Do List.”
Bring your To-Do List when you go to your doctor. And, share it with your family or caregivers.
My To-Do List
at least one to-do topic
Medication List for member name, DOB: DOB
Medication List
Prepared on: CMR date
Bring your Medication List when you go to the doctor, hospital, or emergency room. And, share it with your family or caregivers.
Note any changes to how you take your medications. Cross out medications when you no longer use them.
Medication
How I take it
Why I use it
Prescriber
medications
Add new medications, over-the-counter drugs, herbals, vitamins, or minerals in the blank rows below.
Medication
How I take it
Why I use it
Prescriber
Allergies:
Medication List for member name, DOB: DOB
Side effects I have had:
My notes and questions:
Format: CMS Medicare Part D Medication Therapy Management Program Standardized Format, Form CMS-10396 (OMB 0938-1154), format and instructions v12.17.2024. Kidney dosing rows and interactions are quoted from FDA labels (openFDA). Preview, pending pharmacist review; use clinical judgment.
Allergies: