Referral for Domiciliary Medication Management - Home Medicines Review
Medical Benefits Schedule Item 900. Also known as DMMR or HMR

<<Miscellaneous:Date>>

Patient	Community Pharmacy	General Practitioner	
<<Patient Demographics:Full Name>>
<<Patient Demographics:Address>>
<<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>
Phone: <<Patient Demographics:Phone (Home)>>
DoB: <<Patient Demographics:DOB>>
Medicare no: <<Patient Demographics:Medicare Number>>
DVA no: <<Patient Demographics:DVA Number>>	DMMR Australia
Email:referrals@dmmraustralia.com.au
Phone: 03 4313 4122
Fax: 03 9960 2787	<<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
E-mail: <<Doctor:E-mail>>
Provider no: <<Doctor:Provider Number>>
Prescriber no: <<Doctor:Prescriber Number>>	

Medical History
<<Clinical Details:History List>>

Current Medications
<<Clinical Details:Medication List>>

Allergies
<<Clinical Details:Allergies>>

Immunisations
<<Clinical Details:Immunisation List>>

Relevant Progress Notes
<<Summary:Progress Notes (Selected)>>

Relevant Pathology Results
<<Summary:Investigation Results (Selected)>>

Measurements
<<Clinical Details:Measurements>>

Social History	Occupation	
<<Clinical Details:Social History>>	<<Patient Demographics:Occupation>>	

Smoking status	Alcohol consumption	
<<Clinical Details:Smoking>>
Quitting stage: <<Clinical Details:Smoking Quitting Stage>>	<<Clinical Details:Alcohol>>	

Reason for referral for DMMR	Issues that may influence medication use	
<<Reason for referral 1>>

<<Reason for referral 2>>

<<Reason for referral 3>>	To select any item - highlight its checkbox and type x

p poor vision
p hearing problems
p swallowing difficulties
p dexterity
p language and/or literacy problems
p cognition
p other: please specify...

Medication Administration

Medication usually administered by <<Medication usually administered by>>	Dosing Aids

p dosing aid device e.g. Dosett, Webster. Specify brand or type...

p other: please specify...

If a dosing aid is used, it is filled by <<Dosing aid, if used, filled by>>	
Disease Monitoring Devices

p peak flow meter
p BP monitor
p blood glucose meter
p INR monitor
p other: please specify...
	Medication Administration Devices

p spacer device for respiratory inhalers
p nebuliser pump for respiratory solutions
p other: please specify...

The patient <<Speaks enough English to do the interview>> English to do the interview.

An interpreter <<An interpreter (is/is not) required>> required. The patient's preferred language is <<The patients preferred language is>>.

I HAVE EXPLAINED TO THE PATIENT
x   the process in having a DMMR; and	THE PATIENT HAS CONSENTED:
x   to me releasing to you information about <<Patient Demographics:his/her>> medical history and medications; and	
THE PATIENT UNDERSTANDS THAT:
x   the location of the DMMR is at <<Patient Demographics:his/her>> choice, but preferably in <<Patient Demographics:his/her>> own home; and
x   the pharmacist who will conduct the DMMR will communicate with me information arising from the DMMR; and	THE PATIENT <<Consent to release Medicare/ DVA  Number details>>:
x   to me releasing <<Patient Demographics:his/her>> Medicare no. or DVA no. to you for the pharmacist's payment purposes.

THE PATIENT HAS CONSENTED:
x  to me releasing this information to DMMR Australia who utilises overseas contractors to assist in the provison of this service.

Signed......................................................................................................   Date................................................

<<Doctor:Name>>
<<Doctor:Qualifications>>