Maryland Medicaid Pharmacy Programs

RECIPIENT-KEPT FACTOR INFUSION LOG

Phone: 800-492-5231 or 410-767-5701- Fax: 410-333-5398

201 W.Preston St- Room 409F, Baltimore, MD 21201

Recipient:________MA#:______Phone# (_____)______-______

Current Address: ______

Physician:______Phone# (___ __)______-______Fax# (_____)_____-______

Patient’s Case Manager:______Phone#______Fax# (______)______-___

Date/Time

Circle (I) for Infusion or (D) for Delivery / Units Received (to be added) or Units Infused (to be subtracted) –Specify units per vial and number of vials / Units On-hand after last dose- Specify units per vial and number of vials remaining in the refrigerator / Explain any unusual bleed(s) requiring additional doses-Notify Doctor of such bleed. Specify location where drug is infused if other than home.
I / D / U/vial______x # vials____
U/vial______x # vials____
U/vial x # vials____ / U/vial______x # Vials____
U/vial______x # Vials____
U/vial______x # Vials____
I / D / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____ / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____
I / D / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____ / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____
I / D / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____ / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____
I / D / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____ / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____
I / D / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____ / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____
I / D / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____ / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # Vials____
I / D / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # vials____ / U/vial______x # vials____
U/vial______x # vials____
U/vial______x # vials____

The balance on-hand given to the pharmacist at the time of the call on _____/_____/_____ is: ______U

Original Signature of Recipient or Caregiver’s:______Date:_____/______/_____

Name:______Relationship to the Patient:______

NOTE: It is highly recommended that Recipient/Caregiver keep a record of the Recipient’s clotting factor infusions, especially when drug non-compliance is an issue. The Recipient-Kept Factor Infusion Log is voluntary and may be completed by the Recipient/Caregiver for the purpose of monitoring bleeding patterns and drug utilization. The form should be either directly mailed to the State by the Recipient/Caregiver or handled via the Specialty Pharmacy when an order for more clotting factors is placed with the pharmacy. The pharmacist should ask for the balance of units on-hand at the time of the order. Self-addressed envelopes may be requested from the State by calling 410-767-5701. c:\MSWord\FactorRecipientKeptFactorInfusionLogJul06