Can this template be signed electronically?

Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted. Ensure signer intent, consent to electronic records, attribution, and retention to meet the four-part legal test for validity.

Are there exceptions for e-signing MTM forms?

Some document types are excluded from ESIGN/UETA (for example, wills and certain court filings). For MTM clinical records, the key restriction is patient consent and PHI safeguards rather than a statutory prohibition.

Do I need a BAA with my e-sign vendor?

Yes for PHI: HIPAA requires a Business Associate Agreement when a vendor handles protected health information. Confirm the vendor offers a BAA and implements HIPAA controls.

What authentication level is recommended?

Use at least email link plus optional SMS code for patient signatures; for clinician signatures, consider stronger authentication (organization SSO or multi-factor) to support attribution.

How do I correct an already-signed MTM record?

Create an addendum or corrected entry with date, reason for correction, and signer attribution rather than editing the original signed record. Maintain both versions for audit trails.

How should completed templates be stored?

Store signed copies in the EHR or secure document repository with access controls and retention policies aligned to HIPAA and applicable state retention rules; preserve audit trails and export signed PDFs for long-term access.

Basic MTM Template

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Basic MTM Template

Effective Date:

Parties

Service Provider:

Service Provider Address

Client:

Client Address

Recitals

WHEREAS, Service Provider provides professional services in the ordinary course of business and has the skill and experience necessary to perform the services described in this Agreement; and

WHEREAS, Client desires to engage Service Provider on a month-to-month basis to perform such services under the terms and conditions set forth herein; and

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein, the parties agree as follows:

Scope of Work

Description of services to be performed

Payment Terms

Monthly Fee: $ (invoiced monthly unless otherwise agreed).

Payment schedule and method

Late Payment: If any amount due is not received within days after the due date, Client shall pay a late fee equal to the greater of % per month of the overdue balance or $.

Term and Termination

This Agreement shall commence on and shall continue on a month-to-month basis until terminated in accordance with this Section.

Either party may terminate this Agreement without cause by providing written notice to the other party at least days prior to the desired termination date. Termination for material breach may be immediate if the breaching party fails to cure the breach within days after written notice.

Upon termination, Client shall pay Service Provider for all services performed and reimbursable expenses incurred through the effective date of termination. Any pre-paid but unearned fees shall be refunded to Client within 30 days after termination, unless otherwise agreed in writing.

Confidentiality

Each party (the "Receiving Party") shall hold in strict confidence and shall not disclose to any third party any Confidential Information of the other party (the "Disclosing Party"). "Confidential Information" means non-public information disclosed in any form that is designated as confidential or that, by its nature, should reasonably be understood to be confidential.

The obligations in this section shall not apply to information that: (a) is or becomes publicly available through no fault of the Receiving Party; (b) was rightfully known to the Receiving Party prior to disclosure; (c) is lawfully received from a third party without breach of an obligation of confidentiality; or (d) is independently developed by the Receiving Party without use of or reference to the Disclosing Party's Confidential Information.

If the Receiving Party is legally compelled to disclose Confidential Information, it shall provide the Disclosing Party prompt written notice and reasonably cooperate in any effort to obtain confidential treatment or a protective order.

Liability and Indemnification

Service Provider shall perform services with commercially reasonable skill and care. Except for willful misconduct or gross negligence, neither party shall be liable to the other for consequential, incidental, special, or punitive damages. Each party shall indemnify and hold harmless the other from claims arising out of its own negligence or willful misconduct.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to its conflicts of law principles.

Entire Agreement

This Agreement, including any exhibits or attachments expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals, and communications, whether oral or written. Any amendment to this Agreement must be in writing and signed by both parties.

Additional Provisions

Optional provisions, special instructions, or modifications

Notices under this Agreement shall be in writing and delivered to the addresses set forth above or to such other address as a party may designate by written notice. Notices are effective upon receipt.

Service Provider - Printed Name:

By:

Date:

Client - Printed Name:

By:

Date:

What the Basic MTM Template Is and Who It Serves

The Basic MTM Template is a standardized Medication Therapy Management engagement form used by pharmacists, clinicians, and care coordinators to document a medication review, care plan, and follow-up actions. It captures patient identifiers, current medications, allergies, clinical goals, interventions, and pharmacist recommendations. The template supports clinical documentation, payer billing, and patient communication while providing a consistent record for clinical decisions. When completed accurately, the form streamlines continuity of care across outpatient, community pharmacy, and home health settings and supports audit-ready documentation.

Why a Clear Basic MTM Template Matters

A focused MTM template reduces omissions, speeds clinical reviews, and creates a consistent record for reimbursement and quality reporting. Clear fields help avoid delays in care and provide the attribution and timestamp evidence needed for audits.

Typical Users and Roles for the Basic MTM Template

The Basic MTM Template is most often completed by licensed pharmacists, pharmacy technicians acting under protocol, clinical pharmacists in ambulatory care, and care managers coordinating medication reconciliation.

Community Pharmacists — Document medication history, adherence counseling, and follow-up within pharmacy workflows.
Clinical Pharmacists — Capture medication therapy problems, therapeutic recommendations, and care-plan monitoring.
Care Coordinators — Use for transitions of care, documenting reconciliation and handoffs to primary providers.

It also serves payers and auditors who need a consistent record of the medication review, interventions, and patient education.

Core Sections to Include in a Professional Basic MTM Template

A professional MTM template groups information into logical sections so reviewers can find clinical and administrative details quickly.

Patient Info

Full legal name, date of birth, contact info, and medical record or payer ID to ensure correct patient matching and billing.

Medication List

Complete current medications with dose, frequency, route, start date, and prescriber to support reconciliation and identify therapy problems.

Allergies & Reactions

Active allergies and prior adverse reactions with dates and severity to guide safe therapy changes and alerts.

Clinical Assessment

Document medication-related problems, adherence barriers, lab values, and relevant vitals used to assess therapy effectiveness.

Plan & Interventions

Record recommendations, prescriber communications, patient education provided, referrals, and follow-up timing for continuity.

Signatures & Dates

Signer name, credentials, signature, and date/time stamp to establish attribution for each clinical action.

Required Data Elements and Security Considerations

Patient Name: Full legal name

Date of Birth: MM/DD/YYYY

Medication Details: Drug, dose, frequency

Allergy Record: Allergen and reaction

Clinician Identity: Name and credential

Audit Trail: Timestamp and signer attribution

Step-by-Step: Completing the Basic MTM Template

Follow these sequential steps to complete a compliant MTM encounter record and minimize rework.

01

Collect Patient Data: Verify name, DOB, allergies, and current meds before starting.
02

Review Medications: Assess indications, duplications, interactions, and adherence.
03

Document Findings: Record problems, labs, and clinical rationale for changes.
04

Sign and Date: Complete signer block with credentials and timestamp.

How to Configure the Template for Online Use

Map template fields to your e-sign and EHR workflows so data flows correctly and required fields are enforced.

Field	Configuration
Required Fields	Mark patient ID, medication, and signature as mandatory
Conditional Logic	Show follow-up date only if interventions are selected
Authentication	Use email or SMS code for signer verification
Integrations	Map to EHR and payer systems for automated export

Where to Send the Completed Basic MTM Template

A completed MTM record typically routes to the patient chart, the prescriber, and payer files depending on workflow.

Patient Record: Attach PDF to EHR or pharmacy profile.
Prescriber: Send a copy to the prescriber via secure message.
Payer: Submit documentation for MTM reimbursement when required.
Patient: Provide a patient-facing summary of changes and education.

Digital Signing and Submission: Platform Considerations

Choose an e-sign platform that supports HIPAA workflows, preserves audit trails, and exports standards-compliant signed PDFs.

Authentication: Email, SMS code, or stronger methods
Audit Trail: IP, timestamp, and action log
File Formats: PDF/A and DOCX supported

Typical Timelines and Processing Expectations

Timelines vary by payer and clinical protocol; use consistent internal SLAs to avoid claim delays and ensure timely follow-up.

Initial Review Window:

Complete clinical review within 14 days of referral

Documentation to Payer:

Submit required documentation within 30 days

Follow-Up Contact:

Schedule patient follow-up within 30–90 days as clinically indicated

Claim Submission:

Submit MTM claims per payer guidelines to avoid denials

Audit Readiness:

Retain accessible records for audits per retention rules

Common Mistakes to Avoid When Preparing the Basic MTM Template

Incomplete medication lists leading to unresolved interactions and care delays.
Using informal identifiers instead of official medical record numbers causing mismatched records.
Skipping required payer fields, resulting in claim denials or requests for additional documentation.
Failing to capture signer credentials or timestamps, which weakens audit evidence.

Penalties and Risks of an Incorrect or Incomplete MTM Record

HIPAA Violation: Potential breach notification

Claim Denial: Reimbursement refusal

Clinical Harm: Adverse patient outcome risk

Audit Findings: Corrective action required

Malpractice Exposure: Increased liability risk

Regulatory Penalty: State or federal fines

eSignature Pricing Snapshot for MTM Templates (vendor overview)

Basic vendor pricing and feature availability for comparison. Confirm vendor terms and HIPAA offerings before procurement.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day trial	Varies by vendor	Varies by vendor	Yes, limited	Yes, limited
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

FAQs and Troubleshooting for the Basic MTM Template

Answers to common questions about e-signing, legal validity, PHI handling, and version control for the Basic MTM Template.

Need help? Contact support

Can this template be signed electronically?
Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted. Ensure signer intent, consent to electronic records, attribution, and retention to meet the four-part legal test for validity.
Are there exceptions for e-signing MTM forms?
Some document types are excluded from ESIGN/UETA (for example, wills and certain court filings). For MTM clinical records, the key restriction is patient consent and PHI safeguards rather than a statutory prohibition.
Do I need a BAA with my e-sign vendor?
Yes for PHI: HIPAA requires a Business Associate Agreement when a vendor handles protected health information. Confirm the vendor offers a BAA and implements HIPAA controls.
What authentication level is recommended?
Use at least email link plus optional SMS code for patient signatures; for clinician signatures, consider stronger authentication (organization SSO or multi-factor) to support attribution.
How do I correct an already-signed MTM record?
Create an addendum or corrected entry with date, reason for correction, and signer attribution rather than editing the original signed record. Maintain both versions for audit trails.
How should completed templates be stored?
Store signed copies in the EHR or secure document repository with access controls and retention policies aligned to HIPAA and applicable state retention rules; preserve audit trails and export signed PDFs for long-term access.

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