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Maryland Medicaid Pharmacy Programs

RECIPIENT-KEPT CLOTTING FACTORS ADMINISTRATION RECORD

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

PO Box 2158 Baltimore, MD 21201

Recipient:_________________________MA#:___________________Phone# (_____)______-______

Current Address: ____________________________________________________________________

Physician:______________________Phone# (___ __)_______-_________Fax# (_____)_____-______

Patient’s Case Manager:_______________Phone#______________Fax# (______)______-___

Date/Time

Units Received (to be

Units On-hand after last

Explain any unusual bleed(s)

Circle (I) for

added) or Units Infused (to

dose- Specify units per vial

requiring additional doses-

Infusion or

be subtracted) –Specify units

and number of vials

Notify Doctor of such bleed.

(D) for

per vial and number of vials

remaining in the refrigerator

Specify location where drug

Delivery

is infused if other than home.

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____

I / D

U/vial_______x # Vials____

U/vial_______x # vials____

I / D

U/vial_______x # Vials____

U/vial_______x # vials____

I / D

U/vial_______x # Vials____

U/vial_______x # vials____

I / D

U/vial_______x # Vials____

U/vial_______x # vials____

I / D

U/vial_______x # Vials____

U/vial_______x # vials____

I / D

U/vial_______x # Vials____

U/vial_______x # vials____

I / D

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: This form is mandatory and may be duplicated. Recipient or Caregiver must keep a record of

Recipient’s clotting factor infusions and bleeds for the purpose of monitoring compliance and bleeding patterns.

The form should be sent to the specialty pharmacy when an order is placed. The pharmacist should ask for the

balance of units on-hand at the time of the order and submit this form to the State along with the required

paperwork.

c:\MSWord\Factors_RecipientKeptClottingFactorsAdmRecordNov 08

Recipient-Kept Clotting Factors Administration Record Form - Maryland Medicaid Pharmacy Programs

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