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      Barcode   Notes
Advance Care Planning Advanced Care Planning Order Form      8.18      
               
Bleeding Disorders Center Bleeding Disorders Laboratory Requisition

10189

   3.16      
               
Cancer Services Cancer Genetics Clinic Consult Request

 8361

   6.17  

 BC

 
  CFCC Oncology Referral

 11508

   7.17      
  Lung Cancer Screening Referral 11611   11.18      
               
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

 

10.17

     
  Physician Referral for Outpatient Cardiac Rehabilitation

 4765

   12.18      
               
 Cytology Cytology Outpatient Service

 814

 

3.15

     
               
 Diabetes Diabetes Self-Management Education
and Medical Nutrition Therapy Referral

2535

 

11.18

 

BC

 
 

 DIA10021

   6.18  

 BC

 
 

 DIA10102

   6.18  

 BC

 
  Outpatient Nutrition Counseling Cadillac DIA20151   5.18   BC  
  Patient Insulin Instruction Checklist

 10934

   12.13  

 BC

 
               
 Dialysis Continuous Renal Replacement Therapies (CRRT) Initiation Order

 6423

   6.17  

BC

 
  Medical Nutrition Therapy Referral - Chronic Kidney Disease

 11103

   6.14  

 

 
               
 EEG  EEG Physician Referral

 11110

   4.16  

 BC

 
               
 General & Misc. 48 Hour or Less Stay History and Physical

 545

   3.12  

 BC

 
  Advanced Beneficiary Notice of Non-coverage (ABN) 6146   12.18      
  APP Controlled Substance Prescriptive Authority Delegation      12.16      
  General Consent Form/Confirmation of Informed Consent

 0303

   8.17  

 BC

 
  Know Your Medications Card

 2327

   2.10      
  Mandatory Report of a Maternal Death

 11810

 

9.17

     
  PA Practice Agreement Model      3.17      
  PWS Pin Form 10206    6.16      
  Physician Office Forms Request

 

   9.12      
  Influenza Consent Form

 3717

 

10.15

 

 BC

 
               
Infection Prevention KMHC Immunization Consent Form 11958   10.18      
               
Information Systems Computer System Access Request Form -- PDF *

 

   10.16     *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*    

10.16

     
  4 Steps to Cerner PowerChart Access for Your Staff

 

   6.16      
  Confidentiality Agreement

 195

   9.18      
               
Infusion Clinic Adult CKD - Epoetin - Iron Orders

 10499

   3.17  

BC

 
  Transfusion Order - Outpatient Infusion Clinic

 10693

   12.12      
  IV Iron Orders for Adults

 10105

 

2.17

 

 BC

 
  IVIG Adult Outpatient Order

 8730

 

10.14

     
  IVIG Pediatric Outpatient Order

 8729

   10.14      
  Prolia (Denosumab) Injection

 10132

   12.12  

 BC

 
  Zoledronic Acid Reclast Infusion Order

 8453

   1.15  

 BC

 
               
 Laboratory Advance Beneficiary Notice of Noncoverage

 8704

   6.17  

 BC

 
  Anatomic Pathology Outpatient Services

 814

 

9.14

     
  Laboratory Non-Patient Order -- MHC Grayling Hospital  LAB 20192    10.15      
  PDSS Lab Requisition

 764

 

2.18

     
  Laboratory Supply & Forms Requisition      7.18      
  Lumbar Puncture Laboratory Requisition

 10631

   2.18  

 BC

 
  Outpatient Laboratory Requisition

 975

   2.18      
  Laboratory Forms Request      1.17      
  Semen Analysis

 4969

   11.10      
               
Maternity and Fetal Maternity Non-Stress Test Physician Referral

 11211

 

9.15

 

 BC

 
  Maternity Follow Up

 11809

   10.17  

 BC

 
  Fetal Testing Request

 11808

 

7.18

 

BC

 
               
 Nutrition Medical Nutrition Therapy Referral/Outpatient Nutrition Counseling

2069

   12.14  

 BC

 
  Chronic Kidney Disease: Medical Nutrition Therapy Referral

 11103

   6.14      
  Diabetes Self-Management Education Certificate of Medical Necessity

 2535

   2.15      
  Healthy Weight Center Referral Form

 

   7.12      
               
 Pain Clinic Comprehensive Pain Management Referral Communication

 10095

   9.15  

 BC

 
               
 Physician Lists Physician Communication List Request

 4929

  1.16     Mailing labels, etc.
               
 POAC POAC Consultation Referral

11063

  10.18      
               
Pulmonary Services

 6745

   12.16  

 BC

 
               
               
 Radiology Anesthesia Order for Radiology Procedure

11651

   1.17  

 BC

 
  Barium Enema Preparation Instructions

 11023

 

10.13

     
  Breast Health Center Risk Assessment Questionnaire

 11327

   11.15  

 BC

 
  Breast Imaging Order

 11657

   8.18      
  Breast MRI Information

 8762

   9.18  

 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

   9.18      
  Instructions for Myelograms

 2850

   2.16      
  Mammogram & Bone Density Questionnaire

 10026

   6.10      
  Mammogram Film Release Request

 8638

   4.15  

 BC

 
  MRI Patient Information/Assessment

 4941

   8.17  

 BC

 
  Outpatient Radiology Test Request

 3236

 

9.18

     
  Outpatient Ultrasound Order

 10413

   9.18      
  PET Scan Order

 6532

  12.18  

 BC

 
  Radiology Service Locations 12030   11.18      
  Universal Radiology Order and Prep Forms - Charlevoix Hospital

 1209AB

   3.16      
   

 

                   
Rehabilitation Services Rehabilitation Services Referral

 2245

 

5.17

     
               
 Sleep Disorders Munson Sleep Disorders Center Referral Process

 11495

   3.17      
  In-Hospital Sleep Apnea Test Information

 11166

   9.16      
  Referral Form for an Overnight Pulse Oximetry Test

 11503

   3.16      
  Sleep Apnea Patient Education

 11083

   4.13      
  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            
   Confidentiality Agreement

 195

   2.15      
               
 Surgery Adult Surgical Antibiotic Prophylaxis Protocol

6702

 

9.18

 

 BC

 
  Consent for Lobectomy

 2566

 

3.13 

 

 BC

 
  Scheduling Order Information

 2097

 

10.14

     
  Scheduling Order Information - Fillable Form

 2097

 

10.14