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 Packet
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:

Pre Op Hip Knee Shoulder Orders
Pre Op Spine Surgery
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
Exploratory Lap Colon Bowel PreOp
Surgical Case Request
Surgical Consent
Surgical Consent Spanish
Outpatient Procedure Surgery H_P DC Summary
Stop Bang Questionnaire
Outpatient Endoscopy Admit Orders

Lab Forms:

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

OB & WHS Forms:

OB Admission Order
OB Hyperemesis Admission Order 8-2020
Routine C-Section Admission Orders
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.