0990-PCCC_Houston_Deliveryform

OMB No. 0990-

Exp. Date XX/XX/20XX

SERVICE DELIVERY FORM

TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE MINORITY HEALTH (PCCC) INITIATIVE

Directions: Complete this form at the end of the home visit. Pharmacist will send the completed form to the program coordinator.

Patient Name: _______________________

Pharmacist Name: ____________________

Visit Date: __________________________

The following service(s) have been provided to me today (please check appropriate diagnosis):

• Baseline Screening

  • Blood Pressure

  • Diabetes

• Baseline Knowledge Survey

  • Blood Pressure

  • Diabetes

• Disease State/Monitoring Education

  • Blood Pressure

  • Diabetes

• Medication Management Education

  • Blood Pressure

  • Diabetes

• Other: ____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

Patient Signature: ____________________ Date: ____________________

Pharmacist Signature: _________________ Date: ____________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average (hours)(minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer