Referral for Home Medicines Review (HMR)
Medical Benefits Schedule Item 900. Also known as a DMMR

Patient 	Credentialed Pharmacist or Community Pharmacy	General Practitioner	
<PtFullName> 
Address:<PtAddress>
DOB: <PtDoB>
Phone: <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)>	<AdrName> 
Address: <AdrAddress>
Email: <AdrEmail>
Phone: <AdrPhone>

	<DrName>
<DrAddress>
Provider Number: <DrProviderNo>
Phone: <DrPhone>
Email: <PracEmail>	

<FormattedDate>

Dear Pharmacist,

Please conduct a Home Medicines Review for <PtFullName>. 

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

MBS eligibility and reason for HMR referral:
This patient lives in the community and has been assessed as having a chronic medical condition or complex medication regimen and not having their therapeutic goals met.

<Reason for HMR referral: select all applicable>
<Reason for HMR referral: Other please specify>

Personal Goals and Preferences:
<Personal Goals and Preferences>

Medical History:
<PMHAll>

Allergies/Adverse Reactions
<Reactions>

Current Medications
<CurrentRx>

Medication Management
Regular Community Pharmacy: <Regular Community Pharmacy:>
Dose Administration Aid (DAA): <Uses a Dose Administration Aid (DAA) - dosette, Webster, sachet: if yes, select type of DAA>

Immunisations
<Imm>

Relevant Progress Notes
<Visits>

Measurements
<Observations>

Ethnicity: 
<PtEthnicity>

Family History:
<FamilyHx>

Social History:
<SocialHx>

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

Relevant Pathology Results
<Ix>

I HAVE EXPLAINED TO THE PATIENT or their carer/representative
 <I HAVE EXPLAINED TO THE PATIENT or their carer/representative: the process in having a HMR; and> the process in having a HMR; and	THE PATIENT or their carer/respresentative 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 or their carer/representative UNDERSTANDS THAT:
<THE PATIENT or their carer/representative UNDERSTANDS THAT: the pharmacist who will conduct the HMR will communicate with me information arising from the HMR; and> the pharmacist who will conduct the HMR will communicate with me information arising from the HMR; and	THE PATIENT or their carer/representative 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......................................................................................................   <FormattedDate>
<DrName>
<DrQualifications>
Provider Number: <DrProviderNo>