Developed as part of the Adherence Engagement Platform, this resource promotes patient/physician communication based on principles of motivational interviewing, health literacy, and self-efficacy to achieve patient commitment to adherence. It gives the physician techniques to explore patients’ knowledge about the prescribed medication and it gives the patient 3 basic questions that they need to answer about their condition so they have an understanding of why the medication has been prescribed. The patient has a place to sign a commitment to fill the prescription, take it as prescribed, refill when needed, and keep taking it until told otherwise by a physician. The tear-off portion could be placed in the patient record to record the intervention.