| Service Line |
Form Name |
# |
|
Date
MM/YY |
|
Barcode |
Notes |
| Advance Care Planning |
Advance Care Planning Order Form |
|
|
04.24 |
|
|
|
| |
| Bleeding Disorders Center |
Bleeding Disorders Laboratory Requisition |
10189
|
|
03.16 |
|
|
|
| |
| Breastfeeding |
Medications and Breastfeeding | Patients |
12719 |
|
01.24 |
|
|
|
| |
Medications and Breastfeeding | Providers |
12718 |
|
01.24 |
|
|
|
| |
Pregnancy and Birthing Classes Flyer |
12731 |
|
02.24 |
|
|
|
| |
| Cancer Services |
Cancer Genetics Clinic Consult Request |
8361
|
|
06.17 |
|
BC
|
|
| |
CFCC Oncology Referral |
11508
|
|
03.24 |
|
|
|
| |
Lung Cancer Screening Referral |
11611 |
|
06.22 |
|
|
|
| |
| Cardiac Services |
Admission Cardiothoracic Same-Day Surgery Orders |
2014
|
|
12.09 |
|
BC
|
|
| |
EECP (Enhanced External Counterpulsation) Physician Referral |
8232
|
|
12.18
|
|
|
|
| |
Cardiac Diagnostic Suite Test Request
|
2278
|
|
12.19
|
|
|
|
| |
Physician Referral for Outpatient Cardiac Rehabilitation |
4765
|
|
12.18 |
|
|
|
| |
| Cytology |
Cytology Outpatient Service |
814
|
|
08.19
|
|
|
|
| |
| Diabetes |
Diabetes Self-Management Education
and Medical Nutrition Therapy Referral |
2535
|
|
06.21
|
|
BC
|
|
| |
|
DIA10021
|
|
07.19 |
|
BC
|
|
| |
|
DIA10102
|
|
06.18 |
|
BC
|
|
| |
Outpatient Nutrition Counseling Cadillac |
DIA20151 |
|
05.18 |
|
BC |
|
| |
Patient Insulin Instruction Checklist |
10934
|
|
12.13 |
|
BC
|
|
| |
| Dialysis |
Medical Nutrition Therapy Referral - Chronic Kidney Disease |
11103
|
|
06.14 |
|
|
|
| |
| EEG |
EEG Physician Referral |
11110
|
|
04.16 |
|
BC
|
|
| |
| E-Consults |
MHC E-Consult Patient Information Handout |
12609 |
|
03.23 |
|
|
|
| |
MHC E-Consult Provider-PCP Information |
12610 |
|
03.23 |
|
|
|
| |
| General & Misc. |
48 Hour or Less Stay History and Physical
|
545
|
|
03.12 |
|
BC
|
|
| |
Advanced Beneficiary Notice of Non-coverage (ABN) |
6146 |
|
07.20 |
|
|
|
| |
APP Controlled Substance Prescriptive Authority Delegation |
|
|
12.16 |
|
|
|
| |
Delegation of Parental Rights and Consent to Medical Treatment |
0174 |
|
02.19 |
|
|
|
| |
MHC Patient Authorization for Release of Health Information |
0525 |
|
02.23 |
|
|
|
| |
Know Your Medications Card |
2327
|
|
02.10 |
|
|
|
| |
Mandatory Report of a Maternal Death |
11810
|
|
09.17
|
|
|
|
| |
PA Practice Agreement Model |
|
|
03.17 |
|
|
|
| |
PWS Pin Form |
10206 |
|
06.16 |
|
|
|
| |
Physician Office Forms Request |
|
|
04.24 |
|
|
|
| |
Influenza Consent Form |
3717
|
|
10.15
|
|
BC
|
|
| |
| Infection Prevention |
KMHC Immunization Consent Form |
11958 |
|
01.19 |
|
|
|
| |
| Information Systems |
Computer System Access Request Form -- PDF * |
|
|
12.21 |
|
|
*When submitting a Computer System Access Request Form,
please include a signed Confidentiality Agreement (#195)
if you don't currently have access to Munson's systems. |
| |
Computer System Access Request Form -- WORD* |
|
|
12.21
|
|
|
|
| |
4 Steps to Cerner PowerChart Access for Your Staff |
|
|
06.16 |
|
|
|
| |
Confidentiality Agreement
|
195
|
|
08.21 |
|
|
|
| |
| Informed Consent |
MHC Informed Consent for Procedure
|
0303 |
|
03.23 |
|
BC |
|
| |
MHC Confirmation of Choice to Refuse or Accept Designated Treatments Utilizing Blood Products - ADULT |
0318 |
|
10.23 |
|
BC |
|
| |
| Infusion Clinic |
Adult CKD - Epoetin - Iron Orders |
10499
|
|
11.22 |
|
BC
|
|
| |
Central Line Flush and TPA Protocol - OP Infusion Clinic |
12698 |
|
09.23 |
|
|
|
| |
Central Venous - Outpatient PICC Line Insertion |
G-008AMB
|
|
07.23 |
|
BC
|
|
| |
Electrolyte Replacement Order - OP Infusion Clinic |
12696 |
|
06.23 |
|
|
|
| |
Hydration Order - OP Infusion Clinic |
12519 |
|
05.22 |
|
|
|
| |
InFLIXimab biosim
Load Infusion Order |
12565 |
|
09.22 |
|
|
|
| |
InFLIXimab biosim
Maintenance Infusion Order |
12566 |
|
09.22 |
|
|
|
| |
IV Iron Orders for Adults |
10105
|
|
08.22
|
|
BC
|
|
| |
IVIG Adult Outpatient Order |
8730
|
|
10.14
|
|
|
|
| |
IVIG Pediatric Outpatient Order |
8729
|
|
10.14 |
|
|
|
| |
Prolia (Denosumab) Injection |
10132
|
|
02.24 |
|
BC
|
|
| |
Therapeutic Phlebotomy Order - OP Infusion Clinic |
12697 |
|
09.23 |
|
|
|
| |
Transfusion Order - Outpatient Infusion Clinic |
10693
|
|
07.22 |
|
|
|
| |
Zoledronic Acid Reclast Infusion Order |
8453
|
|
09.20 |
|
BC
|
|
| |
| Laboratory |
Advance Beneficiary Notice of Noncoverage |
8704
|
|
06.17 |
|
BC
|
|
| |
Anatomic Pathology Outpatient Services |
0814
|
|
09.20
|
|
|
|
| |
Laboratory Non-Patient Order -- MHC Grayling Hospital |
LAB 20192 |
|
10.15 |
|
|
|
| |
PDSS Lab Requisition |
764
|
|
02.19
|
|
|
|
| |
Laboratory Supply & Forms Requisition |
|
|
11.23 |
|
|
|
| |
Lumbar Puncture Laboratory Requisition |
10631
|
|
10.21 |
|
BC
|
|
| |
Outpatient Laboratory Requisition |
975
|
|
11.19 |
|
|
|
| |
Semen Analysis |
4969
|
|
07.22 |
|
|
|
| |
Watkins Pharmacy | Serum for Eye Drops |
|
|
02.22 |
|
|
|
| |
| Legal |
MHC Notice of Patient Protections Against Surprise Billing
|
12478 |
|
12.21 |
|
|
|
| |
MHC Notice of Right to Receive a Good Faith Estimate
|
12479 |
|
12.21 |
|
|
|
| |
MHC Detailed Good Faith Estimate |
12480 |
|
01.22 |
|
|
|
| |
| Maternity and Fetal |
Fetal Echocardiogram Referral |
12462 |
|
11.21 |
|
|
|
| |
Maternity Non-Stress Test Physician Referral |
11211
|
|
09.15
|
|
BC
|
|
| |
Maternity Follow Up |
11809
|
|
10.17 |
|
BC
|
|
| |
Maternity Fetal Medicine Referral |
11808
|
|
09.19
|
|
BC
|
|
| |
Pregnancy and Birthing Classes Flyer |
12731 |
|
02.24 |
|
|
|
| |
Birth Preferences |
12302 |
|
08.21 |
|
|
|
| |
| Nutrition |
Medical Nutrition Therapy Referral/Outpatient Nutrition Counseling |
2069
|
|
06.21 |
|
BC
|
|
| |
Chronic Kidney Disease: Medical Nutrition Therapy Referral |
11103
|
|
06.14 |
|
|
|
| |
| Pain Clinic |
Comprehensive Pain Management Referral Communication |
10095
|
|
09.15 |
|
BC
|
|
| |
| Pharmacy |
Munson Specialty Pharmacy - Request for Pharmacy Prior Authorization and Medication Approval Support Services
|
|
|
02.24 |
|
|
After completing and signing the form, either fax to 231-213-8716 or email to Matt Born. |
| |
| Physician Lists |
Physician/Provider Communication List Request |
4929
|
|
04.24 |
|
|
This form can be used to request mailing labels, etc. To request a communication to providers, please submit a Marketing Request. |
| |
| POAC |
POAC Consultation Referral |
11063
|
|
10.18 |
|
|
|
| |
| Pulmonary Services |
|
6745
|
|
01.21 |
|
BC
|
|
| |
| Radiology |
Anesthesia Order for Radiology Procedure |
11651
|
|
01.17 |
|
BC
|
|
| |
Barium Enema Preparation Instructions |
11023
|
|
10.13
|
|
|
|
| |
Breast Health Center Risk Assessment Questionnaire |
11327
|
|
11.15 |
|
BC
|
|
| |
Breast Imaging Order |
11657
|
|
07.20 |
|
|
|
| |
Breast MRI Information |
8762
|
|
09.18 |
|
BC
|
|
| |
Cat Scan Scheduling Questionnaire |
8997
|
|
12.18 |
|
|
Please complete form 8997 [Cat Scan Scheduling Questionnaire] NOT 6425 for scheduling a patient. The form 6425 is for Munson CT use. Form 8997 includes the questions that will be asked at time of patient scheduling. |
| |
CT Lung Cancer Screening Order |
11404
|
|
03.22 |
|
|
|
| |
Incoming Image Request |
11283 |
|
01.19 |
|
BC |
|
| |
Instructions for Myelograms |
2850
|
|
06.20 |
|
|
|
| |
Mammogram & Bone Density Questionnaire
|
10026
|
|
06.10 |
|
|
|
| |
Mammogram Film Release Request |
8638
|
|
09.22 |
|
BC
|
|
| |
MRI Patient Information/Assessment |
4941
|
|
06.21 |
|
BC
|
|
| |
Outpatient Radiology Test Request |
3236
|
|
09.18
|
|
|
|
| |
Outpatient Ultrasound Order |
10413
|
|
06.21 |
|
|
|
| |
PET Scan Order |
6532
|
|
03.24 |
|
BC
|
|
| |
Universal Radiology Order and Prep Forms - Charlevoix Hospital |
1209AB
|
|
03.16 |
|
|
|
|
|
| Rehabilitation Services |
Rehabilitation Services Referral |
2245
|
|
09.20
|
|
|
|
| |
Mary Free Bed at Munson Healthcare Rehabilitation Services Referral |
12391 |
|
07.21 |
|
|
|
| |
| Sleep Disorders |
Munson Sleep Disorders Center Referral Process |
11495
|
|
03.17 |
|
|
|
| |
In-Hospital Sleep Apnea Test Information |
11166
|
|
09.16 |
|
|
|
| |
Referral Form for an Overnight Pulse Oximetry Test |
11503
|
|
03.16 |
|
|
|
| |
Sleep Apnea Patient Education |
11083
|
|
04.13 |
|
|
|
| |
Sleep Disorders Referral |
11393
|
|
10.16 |
|
BC
|
|
| |
| Stoma Therapy |
Outpatient Wound Ostomy Continence Clinic Physician Order |
11383
|
|
10.15 |
|
BC
|
|
| |
| Student Job Shadowing |
Job Shadow Process |
|
|
10.14 |
|
|
|
| |
Job Shadow Release and Waiver of Liability |
|
|
|
|
|
|
| |
| Surgery |
Adult Surgical Antibiotic Prophylaxis Protocol |
6702
|
|
05.23
|
|
BC
|
|
| |
Pediatric Surgical Antibiotic Prophylaxis Protocol |
8956 |
|
01.19
|
|
|
|
| |
Scheduling Order Information |
2097
|
|
07.22
|
|
BC |
|
| Vaccination |
MHC Vaccination Registry Flyer |
12446 |
|
10.21 |
|
|
|