July 2015 Dear Simplify My Meds Patient/Parent/Guardian, Thank you for enrolling in our Simplify My Meds (SMM) program! As a member of this program, you will receive a high-level of personalized service. We are an independent pharmacy and are unable to access the system with Children s Hospital of Wisconsin to verify your medications so please provide the necessary information as requested. Please be aware that we do have multiple Skywalk Pharmacy locations Delafield, Milwaukee, and New Berlin. Each location has their own prescription label with their respective phone number, address and applicable prescription number, however, please call the SMM Program Coordinator for your refill needs. We have two Simplify My Meds Program Coordinators - LaQuana and Stephanie. Your primary contact is Stephanie, however, you may receive a call from either Program Coordinator and they will assist in coordinating which location and/or date would be most convenient for the pick up or shipment of your medications. We ship medications out on Mondays, Tuesdays and Wednesdays of each week. We are required to verify your refill needs and address each month in order to ship your medications. Additionally, most shipments are prepared at our New Berlin location. IMPORTANT CONTACT INFORMATION: Stephanie, Simplify My Meds (SMM) Program Coordinator Skywalk Pharmacy New Berlin Located in Children s Hospital of Wisconsin New Berlin Clinic Direct Phone: (262) 432-7617 Direct fax number: (262) 432-0464 Email: simplify@skywalkpharmacy.com Should you have any questions, please do not hesitate to contact one of our pharmacists or Program Coordinators. Skywalk Pharmacy Located in Children s Hospital of Wisconsin Clinics Building (Main campus) on the Skywalk 9000 W. Wisconsin Ave., Wauwatosa, WI 53226 Phone: (414) 266-1893 Pharmacy Manager: Michael Masse Check out our website at: www.skywalkpharmacy.com Where Your Child is Our Specialty! Skywalk Pharmacy-New Berlin Located in Children s Hospital of Wisconsin New Berlin Clinic - 1 st Floor 4855 S. Moorland Rd., New Berlin, WI 53151 Phone: (262) 432-7613 Pharmacy Manager: Jacob Olson Skywalk Delafield prescription dispensing center supervised by Skywalk Pharmacy-New Berlin Located in Children s Hospital of Wisconsin Delafield Clinic - 2 nd Floor 3195 Hillside Dr., Delafield, WI 53018 Phone: (262) 646-9636
Medication History Date: (Please complete this form so that we may serve you better.) Name: Date of Birth: Address: Phone: Email: Allergies (Medications, food, dyes, etc.): Medicine Reaction Medicine Reaction Medicine Reaction Medicine Reaction **If you have more than five allergies, please continue listing on the next page in additional information. Current Medications: (Please complete to the best of your knowledge.) **If you have more than seven medications, please continue listing on the next page under additional information. Page 1 of 2 Rev. 7.1.14
Social History: Smoke (within last month) Exercise (if so, how long/how often ) Drink alcohol ( 2 drinks/day male, 1 drink/day female) Past Medical History: Asthma Irregular heartbeat (atrial fibrillation) Anxiety COPD Diabetes Depression High cholesterol Cancer High blood pressure Past Surgical History: Appendectomy Angioplasty (balloon surgery) or stent CABG (bypass surgery) Hip replacement Hysterectomy Health literacy issues Consume caffeine (if so, amount per day ) Diet restrictions Heart attack Insomnia (difficulty sleeping) GERD (acid reflux) Ulcers (stomach/intestine) Thyroid disease Stroke Knee replacement Pacemaker/defibrillator Live births # Additional Information: Fax completed forms to: 262-432-0464 Page 2 of 2 Rev. 7.1.14
Patient Agreement We are pleased to welcome you to Simplify My Meds, our coordinated refill program. Advantages of participating in the program include: Increased convenience Each month a Program Coordinator will work with you to coordinate a convenient date to pick up your prescriptions in one order or arrange for a home delivery. Peace of mind from being able to get medications and supplies on time and all at once. More personal contact with the pharmacist to ask questions and discuss medications. Increased understanding of your medication, its purpose, potential side effects. Your prescription records will be easily updated to reflect changes to therapy made by doctors or upon hospital discharge. Your physicians will be contacted on your behalf when prescriptions are out of refills. I understand the program advantages and the following conditions of participation to achieve the maximum benefits from the Simplify My Meds program. I hereby agree to: To accept a phone call each month from the pharmacy to discuss my prescription refills. Pick up medications on my assigned refill date (or be available for delivery, if applicable). Maintain an open dialogue with my pharmacist regarding doctor appointments, hospital/urgent care visits, and changes in my prescriptions. Notify Skywalk of any changes to my phone number or address. Please complete the following information (Please Print): Patient s Name: Patient s Date of Birth: Patient s Primary Mailing Address: If this is an apartment, is the package OK to Leave at the door or lobby? Yes No, please have driver call. 1) Primary Contact: Relationship: Phone #: Home Cell Work Alternate phone #: Home Cell Work
Email address: Can we send a text message (cell phone number required)? Yes No Can we send an email message? Yes No 2) Secondary Contact: Relationship: Phone #: Home Cell Work Alternate phone #: Home Cell Work Email address: Can we send a text message (cell phone # required)? Yes No Can we send an email message? Yes No Please be aware that we are an independent pharmacy and are unable to access the system with Children s Hospital of Wisconsin to verify your medications so please provide the necessary information on the Medication History Form and verify any future changes with the Program Coordinator. I understand that I will be assigned to a Simplify My Meds Coordinator with Skywalk Pharmacy as my primary point of contact. I agree to maintain good communication with the Coordinator and understand that refills may be delayed if I do not speak with the Coordinator in advance of the refill date. I understand that if I do not speak with a representative from Skywalk Pharmacy, my medications will not be available for delivery or pick up. Skywalk Pharmacy will do its best to contact me prior to the time of my medication refills are needed, but ultimately it is my responsibility to contact Skywalk Pharmacy if they are unable to reach me. I have read this document, understand it, and have had all questions answered. Patient Representative (parent or caregiver) Patient or Representative Signature Date Pharmacist Signature Date Office Use Only: Added to Database Medication History Form Received Mailed signed agreement SMM Coordinator Contact Date:
Family Agreement for Foster Care Patient We are pleased to welcome you to Simplify My Meds for foster care patients, our coordinated refill program that works in collaboration with Care4Kids. Advantages of participating in the program include: Increased convenience Each month a Program Coordinator will work with you to coordinate a convenient date to pick up your foster child s prescriptions in one order or arrange for a home delivery. Peace of mind from being able to get medications and supplies on time and all at once. More personal contact with the pharmacist to ask questions and discuss medications. Increased understanding of your medication, its purpose, potential side effects. Your prescription records will be easily updated to reflect changes to therapy made by doctors or upon hospital discharge. Your physicians will be contacted on your behalf when prescriptions are out of refills. I understand the program advantages and the following conditions of participation to achieve the maximum benefits from the Simplify My Meds program. I hereby agree to: To accept a phone call each month from the pharmacy to discuss the prescription refills. Pick up medications on the assigned refill date or be available to receive delivery. Maintain an open dialogue with the pharmacist regarding doctor appointments, hospital/urgent care visits, and changes in foster child s prescriptions. Notify Skywalk of any changes to phone number or address. I understand that if I do not speak with a representative from Skywalk Pharmacy, my medications will not be available for delivery or pick up. Skywalk Pharmacy will do its best to contact me prior to the time of my medication refills are needed, but ultimately it is my responsibility to contact Skywalk Pharmacy if they are unable to reach me. I have read this document, understand it, and have had all questions answered. Patient Name and Date of Birth (please print) Guardian Signature Pharmacist Signature Date Date
Simplify My Meds Phone Call Script 1. SMM Coordinator calls the patient/caregiver. 2. Request to speak to the mother/father/caregiver of. 3. State the reason for the call is to schedule the next refill(s) for. 4. Verify HIPPA by name and date of birth 5. Verify allergies and other medication the patient is currently taking 6. Verify which medications are due for refill and ask if any doses have changed. a. If doses changed, the Coordinator will need to follow up with prescriber if the new script was not sent. b. If a medication is due and they are not needing a refill, ask follow up questions: i. Did the patient miss any doses? ii. How many? iii. Why? 7. Ask if they would like the medication mailed or do they have an upcoming appointment at CHW. 8. Confirm when medication is needed by 9. If mailing: a. Confirm delivery address b. Confirm method of delivery c. Confirm anticipated ship and receive dates d. Confirm someone will be available to receive the package e. Let them know that refrigerated medications are packaged with special packaging 10. Ask if they have any questions for the pharmacist about the medications. 11. Thank them and let them know they will receive a call next month and to call with any questions or concerns.
DATE: TIME: INITIALS: VOICEMAIL/CALLED IN/BROUGHT IN PATIENT NAME: DOB: PHONE: RX # RX NAME NOTES DATE: TIME: INITIALS: VOICEMAIL/CALLED IN/BROUGHT IN PATIENT NAME: DOB: PHONE: RX # RX NAME NOTES Total # of items: PICK UP: DATE & TIME TEXT WHEN READY (CELL PHONE NUMBER) TEXT SENT (DATE, TIME, AND INITALS WHEN TEXT WAS SENT) MAIL/DELIVER DATE SHIPMENT NEEDS TO GO OUT: SPEE DEE (NO CHARGE) SPEE DEE ($5) FED EX OVERNIGHT (NO CHARGE) FED EX OVERNIGHT (PRICE) STANDARD MAIL (NO CHARGE) STANDARD MAIL ($5) VERIFIED ADDRESS? YES SAME ADDRESS YES NEW ADDRESS Educated patient on new mailing location at New Berlin Faxed to New Berlin date/initials Rev. 10.7.14 Total # of items: PICK UP: DATE & TIME TEXT WHEN READY (CELL PHONE NUMBER) TEXT SENT (DATE, TIME, AND INITALS WHEN TEXT WAS SENT) MAIL/DELIVER DATE SHIPMENT NEEDS TO GO OUT: SPEE DEE (NO CHARGE) SPEE DEE ($5) FED EX OVERNIGHT (NO CHARGE) FED EX OVERNIGHT (PRICE) STANDARD MAIL (NO CHARGE) STANDARD MAIL ($5) VERIFIED ADDRESS? YES SAME ADDRESS YES NEW ADDRESS Educated patient on new mailing location at New Berlin Faxed to New Berlin date/initials Rev. 10.7.14