| 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 | | 04.24 | | 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 | | | |