TRANSITIONAL PHARMACY BENEFIT NOTE (1266)    TIU DOCUMENT DEFINITION (8925.1)

This patient has been identified as a new patient waiting for care from
Allergies/Adverse Reactions:
|ALLERGIES/ADR|

Rx(s):
|TIU TPBN ACT OUT MEDS|

Over-the-counter drugs or drugs not issued by VA but currently taking 
(Please List):


the VA and is eligible for the transitional pharmacy program.

Non-formulary Rx requested, not filled:



Formulary Alternatives Recommended:



Next appointment(s):

|TIU TPBN FUTURE APPTS|


Counseling:

The patient and/or the patient's caregiver was offered counseling on
drug, dosage, schedule, route of administration, storage, potential 
side effects, significant drug interactions, and the procedure for 
obtaining refill prescriptions.

Patient Name:  |PATIENT NAME|
Counseling was [] Provided     [] Refused
SSN:           |PATIENT SSN|
Age:           |PATIENT AGE|

Primary Care Provider:  |TIU TPBN PCP|