MTM Locator

MTM ConnectionsTM

SUBMIT MTM PAYER (Program) PROFILE
Important Notice: MTM Locator payer program profiles are intended to highlight a single and unique MTM program. Organizations or payers offering multiple MTM programs should submit a profile for each program. The accuracy and completeness of your profile will be verified prior to being activated and subsequently included in search results on the MTM Locator. Please note however, that APhA and AMCP also reserve the right to notify you that your profile may be deactivated at any time if considered to be inaccurate, inappropriate or incomplete. Fields with an asterisk are required information.

Profile User ID and Password
To maintain your profile on the MTM Locator you will need to create a userID and password to prevent others from altering your profile and allow you to edit and update your profile as required. Neither the userID or password are case sensitive but they must be more than 6 and a maximum of 8 alpha or numeric characters.

Enter a User ID*

Enter a Password*

Profile Contact Information

First Name*

Last Name*

Business Address Line 1*

Business Address Line 2

Business City*

State*

Zip Code*

Business Telephone*

Business E-mail Address*

MTM Program Information

Program Name*

Program Contract Person Telephone*

Program Web Site URL

Pogram Contract Person E-mail*

Program Contract Person Name*

Direct Provider Contracting and Payment*

Yes No

Contracted Service Requirements

Patient Care Services
(Select all that apply)

National MTM Network Participation
(Select all that apply)

Comprehensive medication review
Targeted medication review
Medication adherence
Medication reconciliation
Anticoagulation monitoring
Asthma/COPD
Bone disease/Arthritis)
Diabetes
Heart failure
Immunization administration
Hyperlipidemia
Lifestyle/Wellness
Mental health
Pain therapy
Pharmacokinetic monitoring
Other (list in additional information section)

MedManagement
Med Pathfinder
PharmMD
Mirixa
Outcomes Pharmaceutical Health Care
Other (list in additional information section)

Documentation and Billing Systems
(Select all that apply)

Payer specified web-based system
Self-maintained electronic health record system
Shared access to electronic health record system
On-site paper-based files
Integrated with pharmacy dispensing system
Other (list in additional information section)

Service Delivery Methods
(Select all that apply)

Service Delivery Locations
(Select all that apply)

In-person
Telephonic
Tele-video
Web-based
Mailings/Print
Other (list in additional information section)

Pharmacy practice office
Telephonic
Televideo / Web conferencing
In patient's home/location
Medical clinic or ambulatory care site
Other (list in additional information section)

Contracted Provider Requirements

Certifications or Residency Training
(Select all that apply)

Board of Pharmaceutical Specialties Certification
(Select all that apply)

Not required
Certified diabetes educator (CDE)
Certified asthma educator (CAE)
Certified geriatric pharmacist (CGP)
PGY1 residency training completed
PGY2 residency training completed
Other (list in additional information section)

Not required
Pharmacotherapy
Pharmacotherapy with infectious disease
Pharmacotherapy with cardiology
Nutrition support
Psychiatry
Nuclear
Oncology
Ambulatory Care (effective 2011)

Patient Care Certificate Programs Completed
(Select all that apply)

Pharmacist Education Required
(Select all that apply)

Not required
Medication therapy management
Immunizations
Diabetes
Lipid management
Smoking cessation counseling
Other (list in additional information section)

BSPharm
PharmD
If program requires pharmacists to have graduated
after a specific year please provide year.

States Program Offered/Provided (Select all that apply)

All 50 States, DC and Puerto Rico				AL	AK	AR	AZ	CA	CO
CT	DC	DE	FL	GA	HI	IA	ID	IL	IN
KS	KY	LA	MA	MD	ME	MI	MN	MO	MS
MT	NC	ND	NE	NH	NM	NJ	NV	NY	OH
OK	OR	PA	PR	RI	SC	SD	TN	TX	UT
VA	VT	WA	WI	WV	WY

Additional Information (optional)