Home Affordable Program Form PDF Details

In today's fast-paced world, managing your healthcare can be as complicated as it is crucial. The Home Affordable Program Form serves as a lifeline for individuals navigating the complex terrain of medication management. This comprehensive document, designed to be constantly updated and carried by the individual, acts as a personal medication database, ensuring all healthcare providers have access to a patient's current medication list, including prescriptions, over-the-counter drugs, herbal supplements, and vitamins. Not only does it meticulously record medication names, doses, and the manner in which they are to be taken, but it also lists the reason for each medication, alongside important dates such as when the medication was started or stopped. A notable feature of the form is the provision for individuals to document their allergies and reactions, ensuring that any adverse effects are clearly communicated to healthcare providers. Additionally, it prompts users to include information about their vaccinations and other pertinent health inputs such as their doctor, dentist, or other prescribers, along with the pharmacy details, enhancing the coordination of care across different healthcare platforms. This form, endorsed and reprinted with permission from the Institute for Safe Medication Practices, underscores the importance of patient involvement in their healthcare, emphasizing the role of continuous communication and documentation in fostering safer medication practices.

QuestionAnswer
Form NameHome Affordable Program Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesWashington, Servicer, culty, HOPETM

Form Preview Example

Name:_ __________________________________________

Date Updated:_____________________________________

Universal Medication Form

(Always keep this form with you. Update your list after every doctor and hospital visit)

Name

Address

Date of Birth

Sex (check one)

Height

Weight

 

Male

Female

 

 

Phone Number(s)

Emergency Contact

 

 

 

 

Home:

Name:

 

 

 

 

 

 

 

 

Work:

Relation:

 

 

 

 

 

 

 

 

Mobile:

Phone:

 

 

 

 

 

 

 

 

Allergies and Reactions (please describe what happened when you took the medicine)

Doctor / Dentist / Other Prescriber’s Name

Phone Number

Type of Practitioner / Reason for Seeing

Pharmacy Name

Phone Number

Location

Immunizations (Date of Last Dose)

 

 

 

Other:

 

 

 

Hepatitis B:

Additional Information / Comments

 

 

Zoster (Shingles):

 

 

 

 

 

 

 

Pneumonia:

 

 

 

 

 

 

 

Tetanus, diphtheria, pertussis:

 

 

 

 

 

 

 

Flu:

Reprinted with permission from the Institute for Safe Medication Practices.

Page 1 of _____

 

 

 

 

Name:_ __________________________________________

Date Updated:_____________________________________

Universal Medication Form

List all tablets, patches, inhalers, drops, liquids, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion (like Viagra, nitroglycerin).

Medication

(Brand and Generic Name)

Dose

How and how often you take the medicine

Reason for taking

Date Started Date Stopped Doctor Name

Check here if additional pages of medicine list attached

Reprinted with permission from the Institute for Safe Medication Practices.

Page 2 of _____

 

 

 

 

Name:_ __________________________________________

Date Updated:_____________________________________

Universal Medication Form (Continued)

List all tablets, patches, inhalers, drops, liquids, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion (like Viagra, nitroglycerin).

Medication

(Brand and Generic Name)

Dose

How and how often you take the medicine

Reason for taking

Date Started Date Stopped Doctor Name

Check here if additional pages of medicine list attached

Reprinted with permission from the Institute for Safe Medication Practices.

Page 3 of _____

 

 

 

 

Name:_ __________________________________________

Date Updated:_____________________________________

Personal Medicine Form – Instructions for Use

ƒƒ ALWAYS KEEP THIS FORM WITH YOU. Keep it in your wallet or purse. Give a copy to your emergency contact, another family member, or friend. Take it with you to the pharmacy when you pick up prescriptions.

ƒƒ Doctor and hospital visits. Take this form to all doctor and hospital visits and when you go for appointments and tests.

ƒƒ Allergies. List any reaction you have experienced from medicines that required you to stop taking that medicine such as allergies or bad side effects. Also include any allergy to dye, food, or insects, etc. Please write what happens to you if you are exposed to these things.

ƒƒ Doctor/dentist/other prescriber. List their names and a phone number in case they need to be contacted about your medicines.

ƒƒ Pharmacy. List the pharmacy name, phone number, and location in case there are questions about your medicines.

ƒƒ List of medicines. Write the brand and generic name of each medicine, your dose, how often and how (by mouth, under your tongue, injection, etc.) you take it. List the reason you take the medicine. Note the date you started taking it. If you stop taking a medicine, draw a line through it and list the date you stopped taking it. List all tablets, patches, drops, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion (like Viagra, nitroglycerin). If you need extra pages, write your name on each page.

ƒƒ Update the list. Update your list after every doctor visit when the dose of a medicine is changed, a new medicine is started, or an old one is stopped. Ask your nurse, pharmacist or doctor to help you update your list when you leave the hospital. You need to know what medicines to take and what to stop taking. Bring the updated form to any and all follow up appointments at your doctor’s office, hospital, and pharmacy. Once a year ask your community pharmacist to review and update the list with you.

MS12563

Reprinted with permission from the Institute for Safe Medication Practices.

Page 4 of _____

How to Edit Home Affordable Program Form Online for Free

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Step 1: The first step should be to choose the orange "Get Form Now" button.

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part 1 to filling out false

You have to fill in the Doctor Dentist Other Prescribers, Phone Number, Type of Practitioner Reason for, Pharmacy Name, Phone Number, Location, Immunizations Date of Last Dose, Additional Information Comments, Other, Hepatitis B, Zoster Shingles, Pneumonia, Tetanus diphtheria pertussis, Flu, and Reprinted with permission from the space with the required details.

Entering details in false part 2

Put down the vital information since you are within the Name, Date Updated, Universal Medication Form, List all tablets patches inhalers, Medication Brand and Generic Name, Dose, How and how often you take the, Reason for taking, Date Started, and Date Stopped Doctor Name section.

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The Check here if additional pages of, Reprinted with permission from the, and Page of section is the place where all sides can insert their rights and responsibilities.

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Look at the areas Name, Date Updated, Universal Medication Form Continued, List all tablets patches inhalers, Medication Brand and Generic Name, Dose, How and how often you take the, Reason for taking, Date Started, and Date Stopped Doctor Name and thereafter complete them.

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