NMHC Medication Review

Would you like to receive a “medication checkup”? NMHC would like to assist you in making the most of your pharmacy benefit. Please provide information requested below and we’ll provide recommendations that may save money and/or simplify your medication regimen. Please include over-the-counter products if taken regularly. There is no charge for this service. New Mexico Health Connections uses a HIPAA-compliant platform and survey vendor to collect your personal responses. We will not share the information you provide in this survey with any other party.  

Member Name (required):

Member ID (required):

Phone Number or E-Mail Address (required):

Drug Name and Strength and Condition Being Treated: (List each drug and condition in separate boxes. Be sure to include over-the-counter medications and / or herbal supplements.)

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

Drug Name and Strength and Condition Being Treated:

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