Quarterly Medication Management Report Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.HAVEN ID #Reporting PeriodJanuary to March – due April 15April to June – due July 15July to September – due Oct. 15October to December – due Jan. 15State the frequency of office visits.Has the frequency of visits been changed in the last quarter, and if so, is this change based on your recommendation?Please list the current medications identified in your records/prescribed by you for this professional?Please include medication name and daily dose for each medication.If any of the medications are controlled substances or mood altering medications, what other alternative treatment options been considered?When will the medication plan be reevaluated? (e.g. if chronic use, expect reevaluation at least every three months)Is there a plan to discontinue or taper any medications, and if so, identify the medication?Has this health care professional been compliant with treatment?Since the last report, have you referred this health care professional to any other health care professional for care and treatment, and if so state the name, address and reason for referral?From a treatment perspective, is this professional able to practice with reasonable skill and safety?YesNo Would you like HAVEN to contact you about this participant?YesNoIf necessary, please attach an additional page to provide a confidential statement regarding this professional’s ability to practice with reasonable skill and safety. Drag & Drop Files, Choose Files to Upload I am familiar with HAVEN expectations that any concerns about this individual should be reported to HAVEN immediately, by calling 860.828.3175. More information about HAVEN is available at www.haven-ct.org or by calling us at any time.I AgreeI DisagreePlease note HAVEN’s treatment recommendations and/or requirements of compliance:Continue treatment as long as deemed necessary. Please call HAVEN before considering termination and/or major changes in treatment to discuss. Please notify HAVEN immediately if there are any clinical concerns that would affect the participant’s ability to practice with reasonable skill and safety.Name *FirstLastDateSignature Clear SignaturePhonePreferred method of contactPhoneFaxEmailPlease provide Phone, Fax, or EmailThis information has been disclosed to you from records protected by State and Federal confidentiality rules including 42 CFR Part 2 and Conn. Gen. Stat. Sec. 19a-12a. State and Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and State law. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. This information is also protected from disclosure under State law and information contained herein may not be reproduced or disclosed unless otherwise required by law. 42 CFR Part 2 prohibits unathorized disclosure of these recordsSubmit
