Notification of Multiple Open Charts
Michigan Department of Health and Human Services
Maternal Infant Health Program
Beneficiary Name
Maternal	Infant
See the following chart(s) for additional documentation regarding MIHP services provided for this family.
Beneficiary Name
Maternal	Infant
Beneficiary Name
Maternal	Infant
Beneficiary Name
Maternal	Infant
Beneficiary Name
Maternal	Infant
Beneficiary Name
Maternal	Infant
Beneficiary Name
Maternal	Infant
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

NOTIFICATION OF MULTIPLE OPEN CHARTS INSTRUCTIONS
These instructions are intended to clarify data fields. If you have additional questions, please contact the MDHHS MIHP Team. When serving two or more beneficiaries from the same family, this completed form must be in the chart of every family member. This form is not required if an agency uses family charts, which contain the records of all of the family members being served in one location. Beneficiary name: Insert the beneficiary’s first and last name. Maternal or Infant checkbox: Check whether this is the chart of a maternal or infant beneficiary. In the remaining fields, insert the name of every other family member currently being served and indicate whether the family member is a maternal or infant beneficiary by checking the appropriate box. If the beneficiary is a pregnant woman, insert the names of infants being served. If the beneficiary is an infant, insert the mother’s name or the names of the other infants being served.