IMS



Forms
Item No.Item DescriptionRevision Date
M-22040-AOB Ultrasound Worksheet Main7/2017
MHCC-561Patient Valuables Form9/2022
MM-34079Vaccine Administration Record (Children and Teens)9/2013
Administration/Office
17362MCLA_OPIOID START TALKING5/20
M-10350Thoracic Surgery Clinic Referral1/2022
M-142Travel / Conference Request (3 PART FORM)7/2012
M-2947 INPATIENT REHAB THICKENING LIQUIDS Flyer6/2021
M-34570Request for Financial Assistance9/21
M-5173Dietary Comment Survey4/2022
MGL-044Emergency Department Flyer1/22
MGL-1657Registration Downtime Form
MHCC-1606How to Submit a Safety First Report08/2023
MHCC-17472ICD Indication Form
MHCC-17546PACEMAKER INDICATION FORM03/2023
MHCC-2804cSurprise Billing Protection1/2022
MHCC-2807Prepping & Indexing Quality Monitor Form1/2022
MHCC-335General Consent for Treatment11/2024
MHCC-335 ArabicGeneral Consent for Treatment - Arabic11/2022
MHCC-335 ChineseGeneral Consent for Treatment - Chinese11/2022
MHCC-335 NepaliGeneral Consent for Treatment - Nepali11/2022
MHCC-335 SpanishGeneral Consent for Treatment - Spanish11/2022
MHCC-335 VietnameseGeneral Consent for Treatment - Vietnamese11/2022
MHCC-34354Action Plan After Joint Surgery
MHCC-518Authorization for Photography6/2020
MHCC-548Joint Commission Readiness Guide Flyer08/2022
MHCC-612Request for Scheduled Absence7/2014
MHCC-741Loaner Tracker Form02/2024
MHCC-771Waiver of Right to Free Interpreter Services05/2024
MM-17070Prostate Cancer Diagnosis Summary.4/2021
MMG-42Notice About Lab Results Cling
REG 7 MCR MEDICARE SECONDARY PAYOR QUESTIONNAIRE 1/2018
SURG-006Surgical Instrument Count Form4/2022
testtest04/2023
US 13ULTRASOUND SCRITAL EVALUATION10/2019
Authorizations/Consents
17418Authorization to Release Information (this is a corporate wide form c/o Medical Records)4/28/2015
MHC-CC0125EMTALA Patient Transfer Consent Form6/2022
MHC-CC0125EMTALA Patient Transfer Consent Form6/2022
Behavioral Health
DCH-0086Formal Voluntary Admission Application - Adult04/2019
MC-97Protected Personal Identifying Info, SOM09/2020
PCM-201Petition for Mental Health Treatment, SOM03/2023
PCM-208Clinical Certificate, SOM12/2019
Cancer Center
MHCC-626Low Dose CT Lung Cancer Screening Form04/2023
Compliance
MHCC-550-BNOTICE OF PRIVACY PRACTICES Flyer11/2024
Downtime Paper Forms
MHCC-020RESPIRATORY THERAPY CHARGES - DOWNTIME SLIP08/2024
MHCC-021WOMEN’S HEALTH CHARGE - DOWNTIME SLIP08/2024
MHCC-022PHYSICAL THERAPY CHARGES - DOWNTIME SLIP08/2024
MHCC-023OCCUPATIONAL THERAPY CHARGES - DOWNTIME SLIP08/2024
MHCC-024NURSING CHARGES - DOWNTIME SLIP08/2024
MHCC-025SPEECH THERAPY CHARGES - DOWNTIME SLIP08/2024
MHCC-026CARDIAC REHAB - DOWNTIME SLIP08/2024
MHCC-027NEURO NON-INVASIVE - DOWNTIME SLIP08/2024
MHCC-028SLEEP - DOWNTIME SLIP08/2024
MHCC-029STANDARD DOWNTIME CHARGE FORMS PACKET COVER - DOWNTIME SLIP08/2024
MHCC-030EKG CHARGES - DOWNTIME SLIP08/2024
MHCC-031CATH LAB INVASIVE CHARGES - DOWNTIME SLIP08/2024
MHCC-032NON-INVASIVE CARDIOLOGY CHARGES - DOWNTIME SLIP08/2024
MHCC-033TRAUMA CHARGES - DOWNTIME SLIP08/2024
MHCC-038RADIOLOGY MAMMOGRAPHY - DOWNTIME SLIP08/2024
MHCC-042RADIOLOGY ULTRASOUND CHARGES - DOWNTIME SLIP08/2024
MHCC-046EMERGENCY PROFESSIONAL CHARGES - DOWNTIME SLIP08/2024
MHCC-047BEHAVIORAL HEALTH CHARGES - DOWNTIME SLIP08/2024
MHCC-048ADMIT, DISCHARGE, TRANSFER - DOWNTIME SLIP08/2024
MHCC-049PERIOP CHARGES - DOWNTIME SLIP08/2024
MHCC-050RADIOLOGY BONE DENSITY CHARGES - DOWNTIME SLIP08/2024
MHCC-051RADIOLOGY BONE DENSITY CHARGES - DOWNTIME SLIP08/2024
MHCC-052PHYSICAL THERAPY ACUTE CARE CHARGES - DOWNTIME SLIP08/2024
MHCC-053OCCUPATIONAL THERAPY ACUTE CARE CHARGES - DOWNTIME SLIP08/2024
MHCC-054EMERGENCY ROOM NURSING CHARGES - DOWNTIME SLIP08/2024
MHCC-055RADIOLOGY MRI CHARGES - DOWNTIME SLIP08/2024
MHCC-056RADIOLOGY MRA MRV CHARGES - DOWNTIME SLIP08/2024
Financial
MHCC-542-A Financial Assistance Application Instruction Packet05/2021
MHCC-544Income Verification Form8/2106
General
MGL-120RESPIRATORY DOWNTIME CARE RECORD09/2024
MHCC-060DILAPAN INSERTION Form09/2024
MHCC-17548FOOT SCREENING Form05/2024
MHCC-34046 (34036)Care Management Patient Agreement 03/2024
MHCC-634-BAYBlood Pressure Screening Form - BAY04/2023
MHCC-655Pre-Scheduling Checklist for Cranial/Hypoglossal Neurostimulator Insertion Procedure for Obstructive Sleep Apnea05/2023
MHCC-656Pre-Scheduling Checklist for Sacral Nerve Neurostimulator Insertion Procedure for Urinary Incontinence05/2023
MHCC-657Pre-Scheduling Checklist for Spinal Cord and Peripheral Nerve Neurostimulator Insertion Procedures for Pain05/2023
MHCC-716Declaration Of Medical Indigency03/2022
MHCC-717Statement of Authority11/2023
MHCC-761SUICIDE SEVERITY RATING Form04/2024
HIPAA Related
MHCC-10239 CARD (This item is obsolete. Please order MHCC-705-A)Health Care Agent Appointment (Medical Power of Attorney) Card2/2015
MHC_CC1108.7.7Request for Confidential Communications Form9/2017
Imaging
2244Appointment Notification Form12/2015
Occupational/Convienent Care
MM-34488-BMcLaren Occupational Health/Convenient Care Center Patient Discharge Instructions8/2019
Paper Stock
2 Part Reverse Stock2 Part Reverse2/2021
2 Part Reverse Stock - REAM2 Part Reverse3/2021
3 Part Reverse Stock3 Part Reverse2/2021
4 Part Stock4 Part 2/2021
STOCK 65# Red Cover (4.25 x 5.5)2/2015
STOCKEscript Paper (Blank; Each package contains 500 sheets)10/2014
STOCK8.5 x 11, 20 lb white text, 5 hole drilled at top 1/21/2015
STOCKEscript Paper (Blank; Each package contains 500 sheets)10/2014
Sleep Diagnostic Center
M-17982Direct_Referral_Order9/2015
Stroke
MHCC-17545Heart Health and Stroke Screening04/2023
MHCC-685Primary Stroke Thrombolytic Flowsheet01/2024
MHCC-716Mechanical Thrombectomy Notations10/2023
MHCC-735Comprehensive Stroke Critical Care Flowsheet01/2024
MHCC-736Comprehensive Stroke Thrombolytic Flowsheet01/2024
MHCC-774STROKE PATIENT SURVEY07/2024