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Dear Pharmacist, Thank you for your interest in becoming an Outcomes® referral pharmacist. Outcomes is seeking pharmacists to provide MTM services for patients who do not have access to such services at their primary pharmacies. Any network pharmacist can be considered for this opportunity. Please complete the information below, along with the attached documents, and fax them back to Outcomes at 515.237.0002. If you have any questions, please contact us at 515.237.0001. Thank you, The Outcomes Provider Services Team ------------------------------------------------------------------------------------------------------- Referral Pharmacist General Information: (please print) First Name: ____________________ Last Name: ______________________________ Phone number: _________________ Email: __________________________________ Outcomes Pharmacist ID: (example: IA12345) ____________________________________ MTM Center ID (example: 991234)/NCPDP:______________________________________ 1.) Service Type:

____ Face-to-face ____ Phone-based 2.) States where you can perform face to face MTM (check all that apply)

___AL ___AK ___AZ ___ AR ___CA ___CO ___CT ___DE ___FL ___GA

3

4

___HI ___ID ___ IL ___ IN ___ IA ___ KS ___ KY ___LA ___ME ___MD

___MA ___NY ___NC ___ ND ___OH ___OK ___OR ___PA ___RI ___SC

601 E Locust Suite 200 Des Moines IA 50309-1946

515.237.0001 (voice) 515.237.0002 (fax)

www.getoutcomes.com

___SD ___MI ___MN ___MS ___MO ___MT ___NE ___NV ___NH ___NJ

___NM ___TN ___TX ___ UT ___VT ___VA ___WA ___WV ___WI ___WY

.) Distance willing to travel: ____ 5-10 miles _____10-20 miles _____30-40 miles _____40+ miles

.) Additional Languages you speak (check all that apply): ___ Arabic ___ Japanese ________________ Other (please list) ___ Chinese ___ Portuguese ________________ ___ French ___ Russian ___ German ___ Spanish ___ Hindi

• 601 E Locust Suite 200 Des Moines IA 50309-1946

515.237.0001 (voice) 515.237.0002 (fax)

www.getoutcomes.com

Outcomes Pharmaceutical Health Care®

Medication Therapy Management (MTM) Program Patient Referral Overview

Process After the referral pharmacist has completed the necessary steps (see below), patient referrals will occur from Outcomes® on a graduated basis. Patients will be referred by being placed on the patient list for the appropriate MTM Center in the Outcomes system. It is the responsibility of the referral pharmacist to contact the referred patient to offer and schedule MTM services (Ex. Comprehensive Medication Review). Outcomes will monitor provider performance to ensure services meet quality standards. Successful providers will receive additional patients, when available. Referral Pharmacist Expectations Before receiving referred patients:

1. Sign and return the “Patient Referral Overview” document to Outcomes; sign and return the HIPAA Privacy Policy document to Outcomes

a. Fax – 515.237.0002 (ATTN: Clinical Services) 2. Update “My Profile” in the Outcomes system so mailbox alerts are received at an external

email address (important messages regarding patient referrals will be sent via the internal Outcomes system mailbox)

After receiving referred patients:

1. Within one (1) week of referral a. Contact all referred patients to offer and schedule MTM services b. Attempts to contact each patient should be made at least three (3) times before a

Patient Refusal of service should be documented 2. Within three (3) weeks of referral

a. Provide MTM services for all referred patients who accept the service 3. Within four (4) weeks of referral

a. Document/bill for MTM services provided for all referred patients i. Includes Patient Refusals as well as successful Comprehensive Medication

Reviews ii. Subsequent interventions/claims may be submitted after the 4-week deadline,

if necessary I acknowledge I have reviewed this document: _______________________________________ ___________________________ Pharmacist Signature Date _______________________________________ Pharmacist Printed Name _______________________________________ ___________________________ Pharmacy NABP _______________________________________ Phone

OUTCOMES PHARMACEUTICAL HEALTH CARE POLICY ON PRIVACY, SECURITY, AND CONFIDENTIALITY

(REV 20080305)

Copyright © 2008 Outcomes Pharmaceutical Health Care, L.C.® All rights reserved.

le of Medication Therapy Management (MTM) services.

DO WE COLLECT AND HOW DO E USE IT?

phic information, state license number or her information.

users to omplete a survey rating our products and services.

ste umber(s), date of

e, license and provider identification

e, quantity, days supply, other notes

lusive of any

care operations as permitted under the

ide passwords or

PRIVACY STATEMENT Outcomes Pharmaceutical Health Care® (Outcomes®) has established the following policies and procedures to protect the confidentiality of protected information while permitting the appropriate exchange of information between health care providers, patients, and administrators. These policies explain the collection, storage, use and disclosure of information that Outcomes obtains from consumers, health care entities, and other partners in the course of administering Medication Therapy Management services. Outcomes reserves the right to change, modify, add or remove portions of this statement at any time. PRIVACY AND CONFIDENTIALITY DEFINITIONS The following definitions are used throughout this privacy statement: “Protected Health Information” — any individually

identifiable health information, including information that is not only explicitly linked to a particular individual, but also includes health information with data items which reasonably could be expected to allow individual identification.

“Personally Identifiable Information” — any information that identifies or could be used to identify an individual, as well as any additional data tied to such information.

“Individually Identifiable Patient Information” — information that (i) relates to the mental or physical health or condition of one or more patients, the provision of healthcare to such patient, or payment for the provision of healthcare to such patient and (ii) identifies the individual patient or could be used to identify him or her.

“Registration Information” — certain Personally Identifiable Information provided to Outcomes in the course of registering one or more software applications in the Outcomes System.

“Transaction Data” — all information and data input by a health care provider while documenting or billing health care services using the Outcomes System.

“HIPAA” — the Health Insurance Portability and Accountability Act of 1996 and the related regulations thereto.

“Medication Therapy Management” or “MTM” — analytical, consultative, educational, and monitoring services provided by pharmacists or other appropriate personnel in order to facilitate the achievement of positive therapeutic and economic outcomes from medication therapy.

“Outcomes System” — the systems and procedures developed by Outcomes for the provision, documentation, billing, administration, reporting, advertising, promotion, or sa

WHAT INFORMATION W Registration Information Outcomes may collect Registration Information from a user of the Outcomes System when such user completes an on-line registration form. This information may include contact information, such as name, address and telephone number, as well as demograot Outcomes utilizes the required fields of Registration Information to track use of the Outcomes System, provide support, or respond to user request(s). Outcomes may use this contact and demographic information to alert users to

developments about the Outcomes System. Outcomes may also use this information to contact users about our products and services, and Outcomes may e-mail users to inform them about new version or product releases, or to ask c Transaction Data In the course of administering MTM services, Outcomes may collect Transaction Data generated by users of the Outcomes Sy m, including but not necessarily limited to the following:

Patient: name, address, phone nbirth, gender, identification number

Prescriber: name, state license number, DEA number Practice: name, address, phone and fax numbers, contact namnumbers Patient’s Insurance : health plan name(s), identification numbers Prescription: date, drug, drugs selected but not ultimately prescribed, form, route, strength, dose, directions for usand instructions

Outcomes may disclose some, but not all, of the Transaction Data to one or more of our third party partners such as esearchers, in aggregate form, but excr

Individually Identifiable Patient Information. Outcomes uses the Individually Identifiable Patient Information contained in any Transaction Data solely for the purposes of medical treatment, obtaining payment for such

eatment and healthtrHIPAA Privacy Rule. Correcting or Updating Information Users may correct or update Registration Information by contacting the Outcomes office electronically, telephonically, r by mail. Users may be required to provo

other information for verification purposes. Opting Out of E-mail Communications Users may unsubscribe from one or more e-mailing list by contacting Outcomes via email at info@getoutcomes.com with “Remove” as the subject line. Upon receiving such a request,

utcomes will promptlyO remove the corresponding user from its e-mail contact list. Casual Website Use Outcomes does not collect information about users via the company’s website (www.getoutcomes.com) unless users affirmatively provide such information. Outcomes does collect and store information provided by users affirmatively filling out surveys or online request or registration forms. Outcomes uses such information solely to solicit input regarding current or proposed products so that it may track usage, protect ntellectual property, and delivi er the most useful and

yment for such services and health care

accessible functionality to users. What Information May Be Disclosed? The Outcomes System uses the Individually Identifiable Patient Information contained in any Transaction Data solely for the purposes of Medication Therapy Management and btaining pao

operations. Outcomes is committed to protecting the confidentiality of Individually Identifiable Health Information and does not provide Individually Identifiable Patient Information to any third party other than for purposes of administering MTM

2 (REV 20061000)

Copyright © 2006 Outcomes Pharmaceutical Health Care, L.C. All rights reserved.

o a third party for other urposes is anonymous, aggregated, and not reasonably

ividual patient.

rity by controlling ansmission, storage and access of information that is

tronic data in order to ensure that data ansmitted to or maintained by Outcomes is protected from

ized access.

ch. Outcomes shall ontinually comply with all applicable HIPAA requirements in

rvers, ncryption of electronic transactions, shredding of discarded

ard uch information to at least the same extent as those

the extent practicable, any armful effect from any known unlawful use or disclosure of

pector General, and other ppropriate oversight entities for the purpose of determining

ce with HIPAA.

uch confidential formation and shall not disclose such information except as

quired by law.

regulatory license or approval is required for any ctivity taken by Outcomes or a related party, then the

ements of the regulating entities unless

Shall cooperate in obtaining such license and complying pprovals.

, agent, client, vendor, or subcontractor unless uch non-compliance is resolved to a satisfactory degree and

ts, clients, trade secrets or any other formation that could be considered proprietary by Outcomes

Th

services as permitted by the HIPAA Privacy Rule. Any patient MTM information that is provided tptraceable to the ind DATA SECURITY Data considered private and confidential is maintained under conditions designed to prevent unauthorized access. Outcomes manages electronic data secutrmaintained on Outcomes’ central servers. TRANSMISSION AND STORAGE OF DATA The Outcomes System employs commercial-grade security and encryption of electrunauthor HIPAA Outcomes ensures that any employee or representative coming in contact with Transaction Data or other Protected Health Information is familiar with requirements of HIPAA as it may relate to their contact with sucthe course of its business operations. Outcomes maintains appropriate administrative, physical, and technical safeguards to prevent unlawful use or disclosure of Protected Health Information. Such safeguards may include, but not necessarily be limited to, employee training, password protection of workstations, firewall protection of seedocuments, and physical security of business locations. Outcomes ensures that any agent or subcontractor to whom it provides Protected Health Information is obliged to safegusapplicable to Outcomes with respect to such information. Outcomes shall mitigate, to hProtected Health Information. Outcomes shall make its internal practices, books, and records relating to the use and disclosure of Protected Health Information available to the Centers for Medicare and Medicaid Services (CMS), the US Department of Health and Human Services (HHS), the US InsaOutcomes’ complian TRADE SECRETS Employees and representatives of Outcomes may from time to time be exposed to trade secrets, proprietary, or otherwise confidential information belonging to Outcomes or another party, including the Outcomes System. Such employees and representatives shall keep in confidence all sinspecifically authorized or as re LAWS AND REGULATIONS Outcomes requires all employees, representatives, agents, clients, vendors, and subcontractors to comply with all federal, state and local laws, rules, and regulations which are applicable to carrying out their respective obligations with Outcomes. In the event a governmental agency determines that anyaparties:

Shall be bound by and govern themselves in accordance with the requir

and to the extent that the parties challenge such requirements.

with such a COMPLIANCE Failure to comply with this policy on Privacy, Security, and Confidentiality shall cause Outcomes to terminate its relationship with any such non-compliant employee, representativestimeliness. ACKNOWLEDGEMENT In the course of employment, internship, clerkship, agency or other relationship with Outcomes, the undersigned individual may review medical and financial records of clients, providers, patients, and Outcomes that are considered Protected Health Information, trade secrets, or are otherwise confidential (collectively “Confidential Information”). Such Confidential Information may include oral, written, electronic, or recorded information which indicates the nature or identity of professional practice patterns, financial performance, covered members, patieninor another party.

e undersigned agrees as follows:

vided a copy of these policies and sufficient time to read and comprehend the content prior

I have been pro

to signing below.

t improperly use or disclose any Protected Health Information, trade secrets, or other

I acknowledge that I will no

confidential information.

a fine not to exceed $500 for a first offense and not to exceed

I understand that in the event I improperly use or disclose Confidential Information, I may be subject to disciplinary action including termination of employment or other relationship with Outcomes. I understand that I may also be found guilty of a serious misdemeanor under Iowa Code Section 228, which is punishable by

$5,000 in the case of each subsequent offense.

shall survive termination, expiration, or discontinuation of my employment or other relationship with Outcomes.

______________________________________

_______________________________________

_______________________________________

___________________

___________________

EMAINDER OF PAGE INTENTIONALLY LEFT BLANK

I understand the obligations contained herein

PHARMACIST SIGNATURE PHARMACIST NAME PHARMACY NABP DATE R