Cardiovascular Practice Transformation program (CPT) 2023-2024
Issues submitting forms should be sent to lludwig@cpesniowa.com
What type of submission are you making today? (Note: labs & vitals only need to be reported in the month that they are gathered. If you have reported once and nothing has changed you do not need to update it again until you receive updated data.)
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Baseline (Initial) Submission: I am submitting a brand new patient I will be monitoring.
Follow-up: I am submitting updated data on a previous submission.
Patient Identification Number (Unique patient ID # generated from your Pharmacy Management System or unique pharmacy created #)
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Please be sure to submit the EXACT same Patient ID each time for effective data collection.
Pharmacy Name & NPI
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Please Select
Adel Healthmart (1609864818)
All Care Health Center (1124461363)
Atkins Family Pharmacy Inc (1063491488)
BCHC Oelwein Pharmacy (1588274302)
Bedford Drug (1366457996)
Bennett Pharmacy (1750423810)
Brehme Drug (1558318766)
Capstone Pharmacy (1669865762)
Center Pharmacy (1326027988)
Center Point Family Pharmacy Inc (1750360186)
Central City Family Pharmacy Inc (1679552004)
Cherokee Main Street Pharmacy (1124268396)
Clark's Pharmacy (1285732503)
Clayton Drug Elkader (1417457656)
Clayton Drug Strawberry Point (1083985923)
Clayton Drug Sumner (1184995029)
Clinic Pharmacy (1194816546)
Clinic Pharmacy (1730245093)
Community Pharmacy Lake City (1063971398)
Community Pharmacy Lake View (1235698564)
Community Pharmacy of Sac City (1871142422)
Community Pharmacy Rockwell (1316406648)
Cornerstone Apothecary (1457590879)
Cornerstone Apothecary (1518148956)
Cornerstone Apothecary (1902156342)
Daniel Pharmacy (1043256050)
Denver Drug (1124192539)
Donlon Pharmacy (1669554457)
Dowd Drug (1538235304)
Drilling Pharmacy (1336166214)
Eagle Grove Pharmacy, Inc (1316968373)
Estherville Pharmacy (1063562890)
Evans Crossing Pharmacy (1023505542)
Greenwood Drug (1811084056)
Hartig Drug #34 (1417566191)
Holstein Community Pharmacy (1538647797)
Hughes Healthmart Pharmacy (1942379367)
INFOCUS Pharmacy Services (1194380717)
Koerner-Whipple Pharmacy (1184786113)
Kohll's Rx (1073088019)
Lagrange Pharmacy (1831271998)
Lehan Pharmacy (1700891397)
Lewis Family Drug #55 (1679662290)
M & M Care (1063177293)
Mahaska Drugs Inc (1720006372)
Main at Locust Pharmacy and Medical Supplies (1184781940)
Manning Pharmacy, Inc (1518052612)
Medical Associates Pharmacy (1396782991)
Medicap Pharmacy (1134647100)
Medicap Pharmacy (1699887547)
Medicap Pharmacy (1538253943)
Medicap Pharmacy #8003 (1669408175)
Medicap Pharmacy #8011 (1679764294)
Medicap Pharmacy #8023 (1154848273)
Medicap Pharmacy #8036 (1093764086)
Medicap Pharmacy #8043 (1255399663)
Medicap Pharmacy #8051 (1598182206)
Medicap Pharmacy #8052 (1528017647)
Medicap Pharmacy #8057 (1821047945)
Medicap Pharmacy #8095 (1174617583)
Medicap Pharmacy #8207 (1578014213)
Medicap Pharmacy #8211 (1730500794)
Medicap Pharmacy #8230 (1124086533)
Medicap Pharmacy #8240 (1831409846)
Medicap Pharmacy #8247 (1912956020)
Medicap Pharmacy #8256 (1023044179)
Medicap Pharmacy #8269 (1932523461)
Medicap Pharmacy #8318 (1609803964)
Medicap Pharmacy #8347 (1942452230)
Medicap Pharmacy 8008 (1316002744)
Medicap Pharmacy 8406 (1639372055)
Medicap Pharmacy LTC (1306913983)
Mercy One Dubuque LTC (1669569521)
MercyOne Cascade Pharmacy (1528155710)
MercyOne Dubuque East Pharmacy (1922034131)
MercyOne Dubuque Medical Center Pharmacy (1578650438)
MercyOne Dubuque West Pharmacy (1962573774)
MercyOne Dyersville Pharmacy (1154421469)
Meyer Pharmacy (1194876581)
Montross Pharmacy (1639149990)
Montross Pharmacy (1740370667)
Montross Pharmacy Inc (1952490500)
Mount Vernon Pharmacy (1871687905)
North Liberty Pharmacy (1447355433)
NuCara Pharmacy #10 (1124039763)
Nucara Pharmacy #100 (1720543812)
NuCara Pharmacy #12 (1497766901)
NuCara Pharmacy #16 (1730117581)
NuCara Pharmacy #2 (1942211586)
NuCara Pharmacy #20 (1174682561)
NuCara Pharmacy #24 (1356616403)
NuCara Pharmacy #27 (1124039631)
NuCara Pharmacy #28 (1972521862)
NuCara Pharmacy #30 (1255364469)
NuCara Pharmacy #32 (1922440460)
NuCara Pharmacy #44 (1164516027)
NuCara Pharmacy #6 (1033120548)
NuCara Pharmacy #7 (1861403370)
NuCara Pharmacy #9 (1104837616)
Osterhaus Pharmacy (1861155699)
Owl Pharmacy (1659967578)
Parkersburg Pharmacy (1932257599)
Pexton Pharmacy (1235173451)
Pharmacy on 8th (1467715821)
Reinbeck Pharmacy (1427302660)
Rex Pharmacy inc (1841277282)
Scott Pharmacy (1669587473)
Scott's Thrifty White Drug (1255652210)
Solon Towncrest Pharmacy (1043567050)
Sumpter Pharmacy (1629568795)
Towncrest Pharmacy (1306825179)
Valley Drug Store (1700942802)
Wagner Pharmacy (1497349047)
Washington County Hospital Beans Pharmacy (1609120153)
Wells Hometown Drug (1053896399)
Wells Hometown Drug Keosauqua (1437825569)
Wester Drug, Inc (1407836778)
Wester Drug, Inc. (1578612768)
Wright Pharmacy (1982958997)
Your Neighborhood Pharmacy (1457902314)
Name of person submitting form
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First Name
Last Name
Email
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example@example.com
Date of Service provided
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-
Month
-
Day
Year
Date
Patient Age (please report in years, do NOT include specific date of birth)
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Gender
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Please Select
Male
Female
Other
Transgender
Race
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Please Select
Caucasian or White
Asian or Pacific Islander
Black
Hispanic
Multiracial
Native American or Alaskan Native
No response
Unknown
Other
Ethnicity
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Please Select
Hispanic
Non-hispanic
No response
Unknown
What is the patient's primary insurance coverage?
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Commercial
Medicaid Managed Care (AmeriGroup, Iowa Total Care, Molina, etc)
Medicare
Uninsured
Other
Were any social determinants of health screened for during the visit?
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Yes
No
It was offered but patient declined participation.
If yes, please check all true answers below:
None found
Food
Transportation
Housing
Safety (physical or emotional)
Childcare
Employment
Other
Was a referral made or assistance provided to the patient for a social determinant issue identified above?
Screened, Referral made
Screened, No referral made
Screened, Patient plans to self-resolve
Does patient use tobacco currently?
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Yes
No
Check any disease states for which the patient is currently being treated.
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Hypertension
High Cholesterol
Diabetes
If HTN, provide recent blood pressure reading.
ex: 140/95
Date of BP reading above
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Month
-
Day
Year
Date
Was BP above measured by pharmacy staff or reported by patient?
Measured
Reported
Is patients BP at goal? (BP less than 135/85)
Yes
No
Is patient enrolled in Self Management of Blood Pressure (SMBP)?
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Yes
No
If diabetes, provide the latest A1c reading.
ex: 8.7
Date of A1c reading
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Month
-
Day
Year
Is patient's A1c at goal? (ex: A1c 7% or lower)
Yes
No
Is the patient taking a statin?
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Yes
No
If no, why?
Not indicated/needed
Patient tried in the past and intolerant
Unsure at this time
Prescriber unresponsive to request to initiate
Is patient's cholesterol at goal? (ex: goal LDL per prescriber)
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Yes
No
Unknown
Date of last lipid reading
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Month
-
Day
Year
Date
Total Cholesterol (TC)
HDL
LDL
Has ASCVD risk been assessed? https://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calulate/estimator/
Yes
No
If not at goal, is the patient adherent to their medication therapy?
Yes
No
Did pharmacy staff complete a Medication Reconciliation?
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Yes
No
Is patient enrolled in MedSync?
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Yes
No
Number of Chronic Medications patient is taking monthly
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Was a Medication Therapy Problem (MTP) identified during the visit? (Note: if the patient is not at goal for BP, A1c, cholesterol, etc. that is considered a MTP and an intervention should be made to attempt to improve their outcomes.)
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Yes, (If so, please document MTP in ecare plan submission)
No
Please share any patient success (or challenge) stories that highlight the work you and your team identified during your encounters with this patient. (***Remember no PHI.)
I am affirming that an ecare plan for this patient will be submitted within one week (or less) of this form submission.
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Submit
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