FORMS

Below you will find the most current forms your office should be using for CRMC services and admissions. Please dispose of any other copies of these forms you may have.

Physician Confidentiality Agreement

The form here should be signed by all physicians and office staff using Mckesson Paragon Clinician Hub and OneContent (HPF) to acknowledge the use and privacy of Protected Health Information (PHI).

Individual Confidentiality Agreement

The form here should be signed by all individuals representing an organization that have a need to access Coffee Regional Medical Center’s EMR using Horizon Patient Folder and Physician Webstation to acknowledge the use and privacy of Protected Health Information (PHI)

CRMC Admission packet

The Admission Packet here should be completed and sent with every patient that is directed to the Hospital for admission or services.

Admission Forms:

Admission Order Form
Admission Order Form Adult
Admission Order Form Pediatric
Adult Pneumonia Orders
ASU Form Packet
ASU Lab & Diagnostic Tests
Chest Pain Unstable Angina Myocardial Infarction Orders
Congestive Heart Failure Orders
OB Admission Orders
Routine C Section Admission Orders
Outpatient Endoscopy Admit Orders
Rule Out Sepsis Pediatric
Severe Sepsis Septic Shock
Surgical Case Request
Consent to Surgical or Diagnostic Procedures
Spanish Consent to Surgical or Diagnostic Procedures
Exploratory Lap Colon Bowel PreOp
Routine Hip Knee Shoulder Arthroplasty PreOp
Routine TAH_LAVH PreOp Orders
Outpatient Procedure Surgery History and Physical Form

PET Scan Patient Instructions

PET CT Prior Authorization Form

 

 

Physician Orders for Labs, Diagnostics or Treatment:

Blood or Blood Product Transfusion Orders
Cardiopulmonary Physician Orders
CT Scan Ordering Guide
Diagnostic Imaging Order Form
Diagnostic Imaging Patient Instructions
Imaging For Women Order Form
Histology Request
Iron Dextran Total Dose Infusion Orders
Medical Cytology Request
Outpatient Intravenous and Injection Therapy
Outpatient Laboratory Test Request
Pain Clinic Referral
Interventional Pain Procedures for Imaging Services Referral
Physician’s Laboratory Services OB_GYN Test Request
Prolia (DENOSUMAB) Injection Protocol
Stop Bang Questionnaire

Referral for CRMC Services:

Cardiac Rehabilitation Physician Referral
Referral for Physical Therapy Services

Referral for Rehabilitation Services

Resources

If you have any questions about the use of these forms, please contact the admissions office at CRMC.