Forms for Providers

Body

Forms

 *If a form has a barcode associated with it, please use that version of the form even if the date is the same.

Service LineForm Name     # Date  
MM/YY 
 Barcode Notes
Advance Care PlanningAdvance Care Planning Order Form   06.24   
 
Bleeding Disorders CenterBleeding Disorders Laboratory Requisition

10189

  03.16   
 
BreastfeedingMedications and Breastfeeding | Patients12719 01.24   
 Medications and Breastfeeding | Providers12718 01.24   
 Pregnancy and Birthing Classes Flyer12731 02.24   
 
Cancer ServicesCancer Genetics Clinic Consult Request

 8361

 06.17 

 BC

 
 CFCC Oncology Referral

 11508

  03.24   
 Lung Cancer Screening Referral11611 06.22   
 
Cardiac ServicesAdmission 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   
 
 CytologyCytology Outpatient Service

 814

 

08.19

   
 
 DiabetesDiabetes Self-Management Education
and Medical Nutrition Therapy Referral

2535

 

06.21

 

BC

 
 

 DIA10021

  07.19 

 BC

 
 

 DIA10102

  06.18 

 BC

 
 Outpatient Nutrition Counseling CadillacDIA20151 05.18 BC 
 Patient Insulin Instruction Checklist

 10934

  12.13 

 BC

 
 
Dialysis Medical Nutrition Therapy Referral - Chronic Kidney Disease

 11103

  06.14 

 

 
 
 EEGEEG Physician Referral

 11110

  04.16 

 BC

 
 
E-ConsultsMHC E-Consult Patient Information Handout12609 03.23   
 MHC E-Consult Provider-PCP Information12610 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 Treatment0174 02.19   
 MHC Patient Authorization for Release of Health Information0525 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 Form10206  06.16   
 Physician Office Forms Request

 

  04.24   
 Influenza Consent Form

 3717

 

10.15

 

 BC

 
 
Infection PreventionKMHC Immunization Consent Form11958 01.19   
 
Information SystemsComputer 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 - ADULT0318 10.23 BC 
 
Infusion ClinicAdult CKD - Epoetin - Iron Orders

 10499

  11.22 

BC

 
 Bisphosphonate Zoledronic Acid-Reclast Infusion Order

 8453

 02.24 

 BC

 
 Central Line Flush and TPA Protocol - OP Infusion Clinic12698 09.23   
 Central Venous - Outpatient PICC Line InsertionG-008AMB 07.23 

BC

 
 Electrolyte Replacement Order - OP Infusion Clinic12696 06.23   
 Hydration Order - OP Infusion Clinic12519 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 Clinic12697 09.23   
 Transfusion Order - Outpatient Infusion Clinic

 10693

 07.22   
 
 LaboratoryAdvance 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   
 
LegalMHC Notice of Patient Protections Against Surprise Billing12478 12.21   
 MHC Notice of Right to Receive a Good Faith Estimate 12479 12.21   
 MHC Detailed Good Faith Estimate12480 01.22   
 
Maternity and FetalFetal Echocardiogram Referral12462 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 Flyer12731 02.24   
 Birth Preferences12302 08.21   
 
 NutritionMedical Nutrition Therapy Referral/Outpatient Nutrition Counseling

2069

 06.21 

 BC

 
 Chronic Kidney Disease: Medical Nutrition Therapy Referral

 11103

 06.14   
 
 Pain ClinicComprehensive Pain Management Referral Communication

 10095

  09.15 

 BC

 
 
PharmacyMunson 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 ListsPhysician/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.
 
 POACPOAC Consultation Referral

11063

 10.18   
 
Pulmonary Services

 6745

  01.21 

 BC

 
 
RadiologyAnesthesia 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 Request11283 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

 

05.24

   
 Outpatient Ultrasound Order

 10413

 06.21   
 PET Scan Order

 6532

 04.24 

 BC

 
 Universal Radiology Order and Prep Forms - Charlevoix Hospital

 1209AB

  03.16   

 

Rehabilitation ServicesRehabilitation Services Referral

 2245

 

09.20

   
 Mary Free Bed at Munson Healthcare Rehabilitation Services Referral 12391 07.21   
 
 Sleep DisordersMunson 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 TherapyOutpatient Wound Ostomy Continence Clinic Physician Order

 11383

  10.15 

 BC

 
 
Student Job ShadowingJob Shadow Process   10.14   
 Job Shadow Release and Waiver of Liability      
 
 SurgeryAdult Surgical Antibiotic Prophylaxis Protocol

6702

 

05.23

 

 BC

 
 Pediatric Surgical Antibiotic Prophylaxis Protocol8956 01.19   
 Scheduling Order Information

 2097

 

07.22

 BC 
Vaccination MHC Vaccination Registry Flyer12446 10.21