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:

Admissions Order Form
Admission Check-list & Packet
Admission Order Form Adult
Admission Order Form Pediatric
Adult Pneumonia Orders
ASU Packet
Bamlanivimab Protocol Packet
Chest Pain Unstable Angina Myocardial Infarction Orders
Congestive Heart Failure Orders
OB Admission Order
OB Hyperemesis Admission Order 8-2020
Routine C-Section Admission Orders
Outpatient Endoscopy Admit Orders
Rule Out Sepsis Pediatric
Severe Sepsis Septic Shock
Surgical Case Request
Surgical Consent
Surgical Consent Spanish
Exploratory Lap Colon Bowel PreOp
Pre Op Hip Knee Shoulder Orders
Pre Op Spine Surgery
Routine TAH_LAVH PreOp Orders
Outpatient Procedure Surgery H_P DC Summary
PET Scan Patient Instructions
PET CT Prior Authorization Form
Outpatient Procedure Cardiac Cath PCI
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

Physician Orders for Labs, Diagnostics or Treatment:

Blood or Blood Product Transfusion Orders
Cardiopulmonary Outpatient Orders
Congestive Heart Failure Referral Form
CT Scan Ordering Guide
CRTD or ICD Implantation Criteria Checklist
Diagnostic Imaging Order Form
Diagnostic Imaging Patient Instructions
Imaging For Women Order Form
Heart & Vascular Out-Patient Orders
Histology Request
Iron Dextran Total Dose Infusion Orders
Low Dose CT order 4-22
Medical Cytology
Outpatient Intravenous and Injection Therapy
Outpatient Lab 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
Cardiac Rehab Physician Referral

Outpatient Forms:

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

Referral for CRMC Services:

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 the use of these forms, please contact the admissions office at CRMC.