Personal Medication List

PERSONAL MEDICATION LIST FOR :
This medication list may help you keep track of your medications and how to use them right.
•
•
•
Use blank rows to add new medications. Then fill in the dates you started using them.
Cross out medications when you no longer use them. Then write the date and why you
stopped using them.
Ask your doctors, pharmacists, and other
healthcare providers to update this list at every
Keep this list up-to-date with:
visit.
If you go to the hospital or emergency room, take this
list with you. Share this with your family or
caregivers too.
prescription
medications over the
counter drugs herbals
vitamins
minerals
DATE PREPARED:
Allergies or side effects:
Medication:
How I use it:
Why I use it:
Other:
Date I started using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Other:
Date I started using it:
Why I stopped using it:
Prescriber:
Date I stopped using it:
Prescriber:
Date I stopped using it:
Form CMS-10396 (01/12)
Form Approved OMB No. 0938-1154
Page 1 of 3
PERSONAL MEDICATION LIST FOR:
(Continued)
Medication:
How I use it:
Why I use it:
Other:
Date I started using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Other:
Date I started using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Other:
Date I started using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Other:
Date I started using it:
Why I stopped using it:
Prescriber:
Date I stopped using it:
Prescriber:
Date I stopped using it:
Prescriber:
Date I stopped using it:
Prescriber:
Date I stopped using it:
Form CMS-10396 (01/12)
Form Approved OMB No. 0938-1154
Page 2 of 3
PERSONAL MEDICATION LIST FOR
Medication:
How I use it:
Why I use it:
Other:
Date I started using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Other:
Date I started using it:
Why I stopped using it:
Prescriber:
Date I stopped using it:
Prescriber:
Date I stopped using it:
Other Information:
If you have any questions about your medication list, call GuildNet Pharmacy Services at 1888-447-0321, Monday to Friday, 9 am to 5 pm. If you have a speech or hearing impairment
and use a TDD, call 1-866-248-0640 Monday to Friday, 9 am to 5 pm.
This information is available for free in other languages. Please contact our Member Service using
the number provided.
Esta información esta disponible en otros idiomas a gratis. Por favor llame a Servicios a los
Clientes, al 1-800-815-0000 por información adicional. (Los usuarios de TTY deben llamar al 1800-662-1220). Se atiende de lunes a viernes, de 8 a. m. a 8 p. m. Servicios a los Clientes tienen los
servicios gratuitos de intérprete de idioma disponibles para altavoces de no-inglés
GuildNet Gold and GuildNet Health Advantage are HMO-POS SNP plans with Medicare and New
York State contracts. Enrollment in GuildNet Gold and GuildNet Health Advantage depends on contract
renewal.
H6864_MGM14_32 MTMP Personal Medication List_Accepted
Form CMS-10396 (01/12)
Form Approved OMB No. 0938-1154
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