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

Patient	Credentialed Pharmacist or Community Pharmacy	Referring General Practitioner	
Patient Details:
<PtDetails>
DOB: 
<PtDoB>
Phone Number: 
<PtPhoneMob> <PtPhoneH>
Medicare / DVA Number: <PtMCNo> <PtDVANo> <PtDVACard>
Medicare Ref: <PtMCLine>
Contact Details:
<Contact details (if person other than patient is required to arrange appointment)>	Addressee:
<AdrDetails>
Email: 
<AdrEmail>
	Doctor Name: 
<DrName>
Provider Number: 
<DrProviderNo>
Email: 
<PracEmail>	

<FormattedDate>

Dear Pharmacist,

Please conduct a Home Medicines Review / DMMR for <PtFullName>. I have included their medical history, current medications, pathology results and additional information relevant to the Medication Review.

The patient <Speaks English> and an interpreter <interpreter is required>. The patient's preferred language is <Preferred language>

Reason for DMMR Referral:
<Reason for DMMR referral>
<Reason for DMMR referral: Other please specify>

Personal Goals and Preferences:
<Personal Goals and Preferences>

Allergies/Adverse Reactions
<Reactions>

Medical History:
<PMHAll>

Current Medications
<CurrentRx>

Immunisations
<Imm>

Measurements
<Observations>

Ethnicity: 
<PtEthnicity>

Family History:
<FamilyHx>

Social History:
<SocialHx>

Issue that may influence medication use: 
<Issue that may influence medication use:>  
<Issue that may influence medication use: Other please specify>

Aids or other equipment used:
<Aids or other equipment used:>
<Aids or other equipment used: Other please specify>

Relevant Pathology Results
<Ix>

I HAVE EXPLAINED TO THE PATIENT
 <I HAVE EXPLAINED TO THE PATIENT: the process in having a DMMR; and> the process in having a DMMR; and	THE PATIENT HAS CONSENTED:
<THE PATIENT HAS CONSENTED: to me releasing to you information about their medical history and medications; and> to me releasing to you information about their medical history and medications; and	
THE PATIENT UNDERSTANDS THAT:
<THE PATIENT UNDERSTANDS THAT: the DMMR interview must occur face to face at the patient's home unless there are exceptional circumstances. Approval to conduct a DMMR at an alternative location must be ontained in advance; and> the DMMR interview must occur face to face at the patients own home, unless there are exceptional circunstances. Approval to conduct a DMMR at an alternative location must be obtained in advance.
<THE PATIENT UNDERSTANDS THAT: the pharmacist who will conduct the DMMR will communicate with me information arising from the DMMR; and> the pharmacist who will conduct the DMMR will communicate with me information arising from the DMMR; and	THE PATIENT HAS CONSENTED: 
<Consent to release Medicare/DVA number>  to me releasing their Medicare no. or DVA no. to you for the pharmacist's payment purposes.	

Signed......................................................................................................   Date: 
<DrName>
<DrQualifications>
Provider Number: <DrProviderNo>