Residential Medication Management Review consent

A Residential Medication Management Review (RMMR) is a comprehensive review of your medications to identify,
resolve and prevent medication related problems. It is carried out by an accredited consultant pharmacist (Service
Provider) after referral by your General Practitioner (GP). The results of the review are communicated to your GP
and to the residential aged care facility. It may be repeated (with referral) after 24 months since your last review was
undertaken, or as your GP requests e.g. if there has been a significant change to your medical conditions and/or
medications. After the initial review, the pharmacist is also permitted to undertake follow-up review/s without GP
referral if the pharmacist considers there is a need for further review.

To complete the review the Service Provider will need to access information about your health and medications and
will also need your Medicare number as this service is fully funded by Medicare. The Service Provider will disclose
your personal information to the Pharmacy Programs Administrator and the Australian Government. The Service
Provider may also disclose your personal information to your Community Pharmacy, other members of your
healthcare team and another Service Provider as a requirement of conducting the service.

The Pharmacy Programs Administrator has a privacy policy that you can read at www.ppaonline.com.au. You can
also obtain a copy of the privacy policy by contacting the Pharmacy Programs Administrator using the contact details
on the website above.

If you do not wish to provide all of the personal information or consent to collect and disclose the personal
information required, the Service Provider will not provide you with the service.

Consent
I consent to the General Practitioner and the Service Provider (including all accredited and registered pharmacists undertaking
the service on behalf of the Service Provider) collecting and disclosing personal information for the purpose indicated above.

Client First Name Jennie Surname George

Signature  Date
01/10/2020
Client Representative (applicable if client is unable to sign in their own right)

Primary Carer / Consent to act on behalf

Guardian

Administrator (with Guardianship)

Other legally recognised person (describe)

First Name Anita Surname Speranza

Signature Date
 01/10/2020