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Medication List for < Insert member name >, DOB: < Insert member DOB > Medication List

Prepared on: < Insert 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

< Insert generic name

and brand name,

strength, and dosage

form for current/active

medications >

< Insert regimen, (e.g., 1

tablet by mouth daily), use of

related devices, and

supplemental instructions as

appropriate >

< Insert indication or

intended medical use

>

< Insert

prescriber name

>

Form CMS-10396 (Expires: 02/24) Form Approved OMB No. 0938-1154 Page 1 of 3

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Medication List for < Insert member name >, DOB: < Insert member DOB > 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:

< Insert allergy information >

Form CMS-10396 (Expires: 02/24) Form Approved OMB No. 0938-1154 Page 2 of 3

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Medication List for < Insert member name >, DOB: < Insert member DOB > Side effects I have had:

< Insert side effect information >

Other information:

< Optional >

My notes and questions:

Form CMS-10396 (Expires: 02/24) Form Approved OMB No. 0938-1154 Page 3 of 3

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