Section 1 Patient/Client Details
Referral Form for NMSS MAR Chart /
The Care Provider should complete Sections 1-6 of this referral form and take to the pharmacy
Section 1 – Patient/client details:
Title: / Date of Birth:
Name: / NHS No:
Address: / For NMSS Office Use only
Postcode: / Carefirst No:
Tel no: / NMSS No / SCR
Section 2 – Provider/Agency Details / Section 3 – Usual pharmacy/dispensary details
Name / Name:
Care Manager: / Address:
Branch:
Tel no: / Tel no:
Section 4 – GP Details
Name: / Surgery:
Section 5 - Additional Information – THIS MUST BE COMPLETED
To Supplier: please note if careworkers are administering, original packs should be supplied unless with prior agreement by the Support Service Manager
Compliance aids should only continue to be provided if the patient can self-administer their medication
Are careworkers administering all medications to the patient?
YES / NO / Note: If “YES” the pharmacy or dispensary will be instructed to pack medication in ordinary packaging for carers to administer from
If the MAR chart is needed only for certain items that the patient has e.g. creams, eye drops etc. please list the required items:
Do the care visits happen for all times medication needs to be administered?
YES / NO / If NO please state arrangements for times when carers are not present to give medications
How long is the MAR chart needed for?
Indefinitely
Other - Please state how long e.g. one month, until a specific date etc.______
THIS FORM IS CONTINUED ON THE NEXT PAGE
The service user named on the previous page is having assisted administration of medication by trained careworkers. Please supply a NMSS MAR chart for the requested agency for the purposes of medication administration (Level 2)
Please note it is the agencies responsibility to reorder prescriptions unless an alternative arrangement is negotiated and agreed with the supplying pharmacy.
Signature: / Date:
Section 7 – Pharmacy/Dispensary Agreement
We will supply a MAR chart to the named patient with each prescription dispensed. I understand we will be issued with a NMSS number, which will be used to claim for payment.
We will store this request securely for our records.
Please call NMSS Office on 01603 217633 if MAR charts are required.
Script ordering service agreed? Yes / No / Delivery service? Yes / No
if no who will be collecting?
Signature: / Date:
Name and Position: / Pharmacy/Practice stamp:
For NMSS Office Use Only
Supplier informed of MSS Number / Date:
Carefirst Care Plan Checked / Date:
Message for care plan to be updated sent: / Date:
Fax referral form once pharmacy/dispensary has signed to Norfolk Medicines Support Service –
01603 224108 or secure email: