Recipient Log

Recipient Prescription Log

A prescription log must be kept for all Medicaid recipients separate from other health insurers. The log sheets must contain the following information:

  • Full name of the recipient
  • Date of service
  • Prescription number
  • Medicaid Identification Number (MID)
  • Signature of patient or agent
  • Relation to recipient

Log sheets must be kept on file for a period of three years and stored for a period of ten years. These log sheets must be easily accessible for Pharmacy Audits.

The following page contains a sample Prescription Signature Log sheet.

Rhode Island Medicaid Program

Prescription Signature Log

Date RX Number Patient Name Patient/Agent (Signature) Relation MID
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           

 

I certify that I have read the reverse of this document and certify that the above prescriptions were dispensed in accordance with those provisions and the rules and regulations of the Rhode Island Medicaid Program pertaining to computer generated prescription claims.

Pharmacy Name and License Number ______________    Pharmacist's Signature ___________________

Pharmacy Address ____________City _____State __ Zip Code_____

Certification

I certify that these services were provided in compliance with Title VI of Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973, and with all other state and federal laws and regulations which prohibit discrimination on the grounds or race, sex, age, color, national origin or handicap.

I certify that the representations on the front of this document regarding the provision of services are correct, that the services were rendered and received this date, have not been previously paid, and that the payment claimed constitutes full and total payment for these services. I certify that the prescriptions referred to hereon were lawfully dispensed to each of the persons whose signatures appears above and that the information contained on each prescription form is likewise accurate and complete and the prescriptions comply with the conditions and the applicable regulations of the R. I. Medicaid Program. I further understand that this form and the information contained hereon will be submitted in support of requests for payment through the Medicaid Program of the State of Rhode Island and that any false statement made hereon may be prosecuted under the appropriate State or Federal law. I agree to keep records necessary to fully disclose the nature and extent of the services provided, and to furnish to the State Agency and to the Medicaid Fraud Control Unit of the Attorney General's Office these records and any other information regarding payments claimed for services rendered that may be requested.

Pharmacist's Daily Certification

Pharmacist's Daily

All pharmacies must reproduce the following certification

Certification statement as part of their end-of-day report. In addition, the dispensing pharmacist must sign and initial each certification statement on a daily basis.

 Certification

I certify that the above representations regarding the provision of services are correct, that the services were rendered and received this date, have not been previously paid, and that the payment claimed constitutes full and total payment for these services. I certify that each of the prescriptions bearing my initials were lawfully dispensed to each of the persons whose name appears above and that the information contained hereon is accurate and complete and the prescriptions comply with the conditions and the applicable regulations of the R.I. Medicaid Program.

I also certify that these services are provided in compliance with Title VI of the Civil Rights Act of 1964 and with all other state and federal laws and regulations which prohibit discrimination on the grounds of race, sex, age, religion, color, national origin or handicap.

I agree to keep records necessary to fully disclose the extent of the services provided, and to furnish to the State Agency and the Medicaid Fraud Control Unit these records and any other information regarding payments claimed for services rendered that may be requested.

I further understand that this form and the information contained hereon will be used to support requests for payment for these services through the Medicaid Program of the State of Rhode Island and that any false statement made hereon may be prosecuted under the appropriate State or Federal Law.

Signature of Dispensing Pharmacist_________________________________

Initials___________    

Signed

Signed

Signed

Signed

Signed

 

 

 

 

 

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