Disclosure and Consent Form

Mednovate Connect
LAUREL, MD 20707
Tel 301-617-0555, Fax 240-554-0316

The Mednovate Connect program powered by Illuminate Health connects you with a personal clinical pharmacist and his/her staff (under the supervision of your personal clinical pharmacist) to serve as a licensed and qualified medication management resource for you. which includes goals you can track in real time. Your medication record, accessible to you as well as your appointed caregiver support through the Med Guide app, may also be made available by you to other members of your health team such as your physicians. You can use the app to schedule virtual phone- based appointments with your clinical pharmacist, ask medication-related questions, improve the way you take your medication (known as medication adherence) and monitor your health and medication related progress.

In order to provide you with this service our clinicians may contact your physician(s), pharmacy or other healthcare providers as well as use additional services such as Dr. First, State Immunization Registries, CRISP and PDMP to assist with your medication histories and medication management when appropriate. Please let us know during enrollment or at any time in the future if you wish to restrict our use of any of the health information resources listed in this section.

For complete and accurate information, you will be requested to provide detailed information about your health, your medications, your healthcare provider (physician), and health insurance provider when in consultation with our clinical pharmacists or using the Med Guide app. Only when requested by the clinical pharmacist and agreed to by you, written consent will be required for us to obtain information from your medical records at your physician’s office or other health care organization (such as a hospital or clinic).

The following services can be provided to you by the Mednovate Connect clinical pharmacist(s):

1. Comprehensive Medication Review of all your medications, both prescription and non-prescription medicines (including herbal supplement, vitamins) upon sign up and at six (6) month intervals.

2. Medication Therapy Management (MTM) to promote safe, effective use of medications including treatment adherence with prescribed medications

3. Review and identification of potential medication errors after you returned home after treatment in a hospital, emergency department, or other new provider (this is known as Medication Reconciliation Service)

4. Review of medication related devices such as blood glucose monitoring supplies, compliance devices, etc.

5. Review of your out of pocket cost of medication and related supplies based on personal budget or drug benefits

6. Ongoing recording of your medication list using Med Guide app.

7. Help with your medication-related questions

8. On-line, telephone and or web video consults with your clinical pharmacist.

You and your family members learn how to:

1. Reduce risk of serious medication errors and adverse effects at home, in hospitals and nursing homes

2. Reduce cost or improve value from prescription and OTC medicines

3. Prevent or monitor for serious drug and drug-herb interactions

4. Identify benefits and improve effects of medicines on illnesses

5. Obtain and use reliable patient education resources about medicines and herbs

6. Address pharmacy needs of the individual (e.g. adherence to treatments, self-medication administration training).

Your use of our web-based platform for this service, known as Med Guide will prompt you and any others such as physicians or family members added to your team to review and accept specific information regarding the app. More information on Mednovate Connect can be found on our website at www.MednovateConnect.com

Your signature below indicates that you allow the provision of services to you by Clinical Pharmacy Associates/Mednovations with Med Guide. Your signature also signifies that you have read and understood the information above. If you are unable to read this document, your signature indicates that it has been explained to you and your questions answered. Copies of this form will be given to you and your healthcare provider whenever medical information is requested and required. In providing this service, and as it relates to patient health Information Mednovate Connect endeavors to comply in all material respects with Confidentiality as required by HIPAA.

Patients Name / Signature:

Clinical Pharmacist Name / Signature: