Below are the most current forms your office should use 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 needs 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 directed to the Hospital for admission or services.

Admission Forms:

Admission Order Form Adult
Admission Check-list & Packet
Admission Order Form Pediatric
Severe Sepsis Septic Shock
Rule Out Sepsis Pediatric
Adult Pneumonia Orders
ASU Admission Packet
ASU Labs and Diagnostic test 04292024
Chest Pain Unstable Angina Myocardial Infarction Orders
Congestive Heart Failure Orders

Cardiology / Cardiopulmonary Forms:

Outpatient Procedure Cardiac Cath PCI
CRTD or ICD Implantation Criteria Checklist
Heart & Vascular Out-Patient Orders
Cardiopulmonary Outpatient Orders

Outpatient IV Therapy Forms:

Bamlanivimab Protocol Packet
Blood or Blood Product Transfusion Orders
Iron Dextran Total Dose Infusion Orders
Outpatient Intravenous and Injection Therapy
Prolia (DENOSUMAB) Injection Protocol
Fact Sheet for LAGEVRIO
Fact Sheet for PAXLOVID
Molnupiravir Guidelines for OutPatient Prescribing
Monoclonal Antibody (Mab) Protocol Orders Out Pt Use
Paxlovid Guidelines for OutPatient Prescribing
Tepezza Protocol for Out Pt Infusion

Radiology Forms:

CT Scan Ordering Guide
PET Scan Patient Instructions
PET CT Prior Authorization Form
Diagnostic Imaging Order Form
Diagnostic Imaging Patient Instructions
Imaging For Women Order Form
Low Dose CT order 4-22


Surgical / Procedure Forms:

PREOP Hip Knee Shoulder Arthroplasty
Pre−Surgery Patient−Reported Functional Assessment Spine
Pre-Surgery Patient−Reported Functional Assessment Knee
Pre−Surgery Patient−Reported Functional Assessment Shoulder
Pre−Surgery Patient−Reported Functional Assessment Hip
Case Request-Universal 04292024
Consent to Surgical or Diagnostic Procedure
Consent to Surgical or Diagnostic Procedure Span
Outpatient Procedure Surgery H & P
Stop Bang Questionnaire

Lab Forms:

Histology Request
Medical Cytology Request
Outpatient Lab test request
Physician’s Laboratory Services OB_GYN Test Request

OB & WHS Forms:

C Section Admin 07.11.2023
OB Admit 01.16.2024
OB Hyperemesis Admission 1/16/2023
Routine TAH_LAVH PreOp Orders

Referral Forms:

Congestive Heart Failure Referral Form
Pain Clinic Referral
Interventional Pain Procedures for Imaging Services Referral
Cardiac Rehab Referral Form 05-2021
Referral for Rehabilitation Services
Healthy Life Clinic Form – Medication Therapy Review

Diabetes Resources:

Diabetes Education OP-DSME-T-OP 03-2019

Diabetes Self-Assessment for Patients 03-2019


If you have any questions about using these forms, don’t hesitate to contact the admissions office at CRMC.