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 Line	Form Name	#	Date MM/YY	Barcode	Notes
Advance Care Planning	Advance Care Planning Order Form		12.24

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	07.25

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	07.21	BC
	MHC Cadillac Hospital	DIA10021	07.19	BC
	MHC Grayling Hospital	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
	MHC Portal Proxy Access Authorization	11068	05.25
	Know Your Medications Card	2327	02.10
	Mandatory Report of a Maternal Death	11810	09.17
	PA Practice Agreement Model		03.17
	Provider Authorization for Use of Web Based Appointment Scheduling	10206	05.24
	Physician Office Forms Request		03.25
	Influenza Consent Form	3717	10.15	BC

Infection Prevention	KMHC Immunization Consent Form	11958	01.19

Information Systems	Computer System Access Request Form -- PDF *		05.25		*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.
	4 Steps to Cerner PowerChart Access for Your Staff		06.16
	Confidentiality Agreement	195	09.25

Informed Consent	MHC Informed Consent for Procedure Printable form Fillable Form	0303	03.23	BC
	Confirmation of Choice to Refuse Designated Treatments Utilizing Blood Products - Adult	0318	09.24	BC

Infusion Clinic	Adult CKD - Epoetin - Iron Orders	10499	07.25	BC
	Bisphosphonate Zoledronic Acid-Reclast Infusion Order	8453	06.24	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	07.25	BC
	IVIG Adult Outpatient Order	8730	10.14
	IVIG Pediatric Outpatient Order	8729	10.14
	Prolia (Denosumab) Injection	10132	06.24	BC
	Therapeutic Phlebotomy Order - OP Infusion Clinic	12697	09.23
	Transfusion Order - Outpatient Infusion Clinic	10693	07.22

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	01.25
	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
	Maternal Fetal Medicine Referral	11808	04.25	BC
	Pregnancy and Birthing Classes Flyer	12731	07.25
	Birth Preferences	12302	11.24

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

Pediatric Psychiatry	Child and Adolescent Psychiatric Consult Referral		03.25

Pulmonary Services	Pulmonary Services Physician Prescription	6745	07.25	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	07.25
	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	05.25
	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	05.25
	Outpatient Ultrasound Order	10413	05.25
	PET Scan Order	6532	04.24	BC

Rehabilitation Services	Rehabilitation Services Referral	2245	09.20
	Mary Free Bed at Munson Healthcare Rehabilitation Services Referral \| East Region		01.24
	Mary Free Bed at Munson Healthcare Rehabilitation Services Referral \| Grand Traverse Region	12391	07.21
	Mary Free Bed at Munson Healthcare Rehabilitation Services Referral \| South Region		01.24
	Mary Free Bed Medical Exercise Consultation		01.24

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	12.24	BC
	Pediatric Surgical Antibiotic Prophylaxis Protocol	8956	01.19
	Scheduling Order Information	2097	07.22	BC
Vaccination	MHC Vaccination Registry Flyer	12446	10.21

Forms for Providers

Forms