IMS
McLaren Forms Committees regulate the various ways printing can be done on forms. Some forms have customizable options, others are preset. If the drop-down menu for printing options is locked, that form can only be printed in those ways.
Forms
Item No.
Item Description
Revision Date
M-22040-A
OB Ultrasound Worksheet Main
7/2017
MHCC-561
Patient Valuables Form
9/2022
MM-34079
Vaccine Administration Record (Children and Teens)
9/2013
Administration/Office
17362
MCLA_OPIOID START TALKING
5/20
M-10350
Thoracic Surgery Clinic Referral
1/2022
M-142
Travel / Conference Request (3 PART FORM)
7/2012
M-2947
INPATIENT REHAB THICKENING LIQUIDS Flyer
6/2021
M-34570
Request for Financial Assistance
9/21
M-5173
Dietary Comment Survey
4/2022
MGL-044
Emergency Department Flyer
1/22
MGL-1657
Registration Downtime Form
MHCC-1606
How to Submit a Safety First Report
08/2023
MHCC-17472
ICD Indication Form
MHCC-17546
PACEMAKER INDICATION FORM
03/2023
MHCC-2804c
Surprise Billing Protection
1/2022
MHCC-2807
Prepping & Indexing Quality Monitor Form
1/2022
MHCC-335
General Consent for Treatment
11/2024
MHCC-335 Arabic
General Consent for Treatment - Arabic
11/2022
MHCC-335 Chinese
General Consent for Treatment - Chinese
11/2022
MHCC-335 Nepali
General Consent for Treatment - Nepali
11/2022
MHCC-335 Spanish
General Consent for Treatment - Spanish
11/2022
MHCC-335 Vietnamese
General Consent for Treatment - Vietnamese
11/2022
MHCC-34354
Action Plan After Joint Surgery
MHCC-518
Authorization for Photography
6/2020
MHCC-548
Joint Commission Readiness Guide Flyer
08/2022
MHCC-612
Request for Scheduled Absence
7/2014
MHCC-741
Loaner Tracker Form
02/2024
MHCC-771
Waiver of Right to Free Interpreter Services
05/2024
MM-17070
Prostate Cancer Diagnosis Summary.
4/2021
MMG-42
Notice About Lab Results Cling
REG 7
MCR MEDICARE SECONDARY PAYOR QUESTIONNAIRE
1/2018
SURG-006
Surgical Instrument Count Form
4/2022
test
test
04/2023
US 13
ULTRASOUND SCRITAL EVALUATION
10/2019
Authorizations/Consents
17418
Authorization to Release Information (this is a corporate wide form c/o Medical Records)
4/28/2015
MHC-CC0125
EMTALA Patient Transfer Consent Form
6/2022
MHC-CC0125
EMTALA Patient Transfer Consent Form
6/2022
Behavioral Health
DCH-0086
Formal Voluntary Admission Application - Adult
04/2019
MC-97
Protected Personal Identifying Info, SOM
09/2020
PCM-201
Petition for Mental Health Treatment, SOM
03/2023
PCM-208
Clinical Certificate, SOM
12/2019
Cancer Center
MHCC-626
Low Dose CT Lung Cancer Screening Form
04/2023
Compliance
MHCC-550-B
NOTICE OF PRIVACY PRACTICES Flyer
11/2024
Downtime Paper Forms
MHCC-020
RESPIRATORY THERAPY CHARGES - DOWNTIME SLIP
08/2024
MHCC-021
WOMEN’S HEALTH CHARGE - DOWNTIME SLIP
08/2024
MHCC-022
PHYSICAL THERAPY CHARGES - DOWNTIME SLIP
08/2024
MHCC-023
OCCUPATIONAL THERAPY CHARGES - DOWNTIME SLIP
08/2024
MHCC-024
NURSING CHARGES - DOWNTIME SLIP
08/2024
MHCC-025
SPEECH THERAPY CHARGES - DOWNTIME SLIP
08/2024
MHCC-026
CARDIAC REHAB - DOWNTIME SLIP
08/2024
MHCC-027
NEURO NON-INVASIVE - DOWNTIME SLIP
08/2024
MHCC-028
SLEEP - DOWNTIME SLIP
08/2024
MHCC-029
STANDARD DOWNTIME CHARGE FORMS PACKET COVER - DOWNTIME SLIP
08/2024
MHCC-030
EKG CHARGES - DOWNTIME SLIP
08/2024
MHCC-031
CATH LAB INVASIVE CHARGES - DOWNTIME SLIP
08/2024
MHCC-032
NON-INVASIVE CARDIOLOGY CHARGES - DOWNTIME SLIP
08/2024
MHCC-033
TRAUMA CHARGES - DOWNTIME SLIP
08/2024
MHCC-038
RADIOLOGY MAMMOGRAPHY - DOWNTIME SLIP
08/2024
MHCC-042
RADIOLOGY ULTRASOUND CHARGES - DOWNTIME SLIP
08/2024
MHCC-046
EMERGENCY PROFESSIONAL CHARGES - DOWNTIME SLIP
08/2024
MHCC-047
BEHAVIORAL HEALTH CHARGES - DOWNTIME SLIP
08/2024
MHCC-048
ADMIT, DISCHARGE, TRANSFER - DOWNTIME SLIP
08/2024
MHCC-049
PERIOP CHARGES - DOWNTIME SLIP
08/2024
MHCC-050
RADIOLOGY BONE DENSITY CHARGES - DOWNTIME SLIP
08/2024
MHCC-051
RADIOLOGY BONE DENSITY CHARGES - DOWNTIME SLIP
08/2024
MHCC-052
PHYSICAL THERAPY ACUTE CARE CHARGES - DOWNTIME SLIP
08/2024
MHCC-053
OCCUPATIONAL THERAPY ACUTE CARE CHARGES - DOWNTIME SLIP
08/2024
MHCC-054
EMERGENCY ROOM NURSING CHARGES - DOWNTIME SLIP
08/2024
MHCC-055
RADIOLOGY MRI CHARGES - DOWNTIME SLIP
08/2024
MHCC-056
RADIOLOGY MRA MRV CHARGES - DOWNTIME SLIP
08/2024
Financial
MHCC-542-A
Financial Assistance Application Instruction Packet
05/2021
MHCC-544
Income Verification Form
8/2106
General
MGL-120
RESPIRATORY DOWNTIME CARE RECORD
09/2024
MHCC-060
DILAPAN INSERTION Form
09/2024
MHCC-17548
FOOT SCREENING Form
05/2024
MHCC-34046 (34036)
Care Management Patient Agreement
03/2024
MHCC-634-BAY
Blood Pressure Screening Form - BAY
04/2023
MHCC-655
Pre-Scheduling Checklist for Cranial/Hypoglossal Neurostimulator Insertion Procedure for Obstructive Sleep Apnea
05/2023
MHCC-656
Pre-Scheduling Checklist for Sacral Nerve Neurostimulator Insertion Procedure for Urinary Incontinence
05/2023
MHCC-657
Pre-Scheduling Checklist for Spinal Cord and Peripheral Nerve Neurostimulator Insertion Procedures for Pain
05/2023
MHCC-716
Declaration Of Medical Indigency
03/2022
MHCC-717
Statement of Authority
11/2023
MHCC-761
SUICIDE SEVERITY RATING Form
04/2024
HIPAA Related
MHCC-10239 CARD (This item is obsolete. Please order MHCC-705-A)
Health Care Agent Appointment (Medical Power of Attorney) Card
2/2015
MHC_CC1108.7.7
Request for Confidential Communications Form
9/2017
Imaging
2244
Appointment Notification Form
12/2015
Occupational/Convienent Care
MM-34488-B
McLaren Occupational Health/Convenient Care Center Patient Discharge Instructions
8/2019
Paper Stock
2 Part Reverse Stock
2 Part Reverse
2/2021
2 Part Reverse Stock - REAM
2 Part Reverse
3/2021
3 Part Reverse Stock
3 Part Reverse
2/2021
4 Part Stock
4 Part
2/2021
STOCK
Escript Paper (Blank; Each package contains 500 sheets)
10/2014
STOCK
65# Red Cover (4.25 x 5.5)
2/2015
STOCK
Escript Paper (Blank; Each package contains 500 sheets)
10/2014
STOCK
8.5 x 11, 20 lb white text, 5 hole drilled at top
1/21/2015
Sleep Diagnostic Center
M-17982
Direct_Referral_Order
9/2015
Stroke
MHCC-17545
Heart Health and Stroke Screening
04/2023
MHCC-685
Primary Stroke Thrombolytic Flowsheet
01/2024
MHCC-716
Mechanical Thrombectomy Notations
10/2023
MHCC-735
Comprehensive Stroke Critical Care Flowsheet
01/2024
MHCC-736
Comprehensive Stroke Thrombolytic Flowsheet
01/2024
MHCC-774
STROKE PATIENT SURVEY
07/2024
