• Archived Cycle 9

    The content in the archive below is defined as archive material pursuant to ADA Title II § 35.104 and ADA Title II § 35.201. If you need assistance accessing information in the archived content or if you require this information in a more accessible format, please contact the Maternal Infant Health Program using the information provided below:

    • Email: mihp@michigan.gov
    • Phone: (833) 644-6447

    Additional Resources can be found on the Notice Under The Americans With Disabilities Act webpage.

     

    Archived Infant Forms: Cycle 9

    • Forms changes for Cycle 9

    Consent Forms

    • 56547 Infant Consent to  Participate
    • 5647 Infant Consent to Participate - Spanish 
    • 5647 Infant Consent to Participate - Arabic   
    • 5653 Infant Consent to Release Protected Health Information 
    • 5653 Infant Consent to Release Protected Health Information - Spanish  
    • 5653 Infant Consent to Release Protected Health Information - Arabic 
    • 5646 Consent to Transfer  
    • 5646 Consent to Transfer - Spanish  
    • 5646 Consent to Transfer - Arabic 

    Risk Identifier, Instructions, Algorithm 

    • Infant Risk Identifier - Worksheet  
    • Infant Risk Identifier - Instructions  
    • Infant Risk Identifier - Algorithm 

    Plans of Care

    • 5637 Infant Plan of Care Part 1  
    • Plan of Care Part 1 - Lead Fact Sheet    
    • Plan of Care Part 1 - Lead Fact Sheet - Spanish
    • 5690 Infant Plan of Care Part 2 - Breastfeeding
    • 5694 Infant Plan of Care Part 2 - Family and Social Support
    • 5693 Infant Plan of Care Part 2 - Feeding 
    • 5691 Infant Plan of Care Part 2 - General Infant Development
    • 5692 Infant Plan of Care Part 2 - Infant Health Care
    • 5695 Infant Plan of Care Part 2 - Infant Safety
    • 5696 Infant Plan of Care Part 2 - Substance Exposed Infant
    • 5989 Infant Plan of Care Part 2 - Transportation
    • 5676 Plan of Care Part 3 - Signature Sheet for Interventions by Risk Level

    Professional Visit Progress Notes

    • 5635 Infant Professional Visit Progress Note 
    • 5641 IBCLC Professional Visit Progress Note

    Care Coordination

    • 5957 Care Coordination (Enhanced Services) - New! For services on or after October 1, 2024

    Rights as an MIHP Participant

    • 5707 Your Rights and Responsibilities as an MIHP Participant 
    • 5707 Your Rights and Responsibilities as an MIHP Participant - Arabic Version 
    • 5707 Your Rights and Responsibilities as an MIHP Participant - Spanish Version 

    Notification and Communication

    • 5638 Infant Care Communication  
    • 5640 Beneficiary Status Notification 
    • 5650 MHP (Word) Communication Tool  
    • 5783 Transfer Fax Cover Sheet  

    Infant Forms Checklist

    • 5700 Infant Forms Checklist 
    • 5699 Infant Forms Checklist for Transfer Received  

    Action Plans

    • 5634 MIHP Action Plan  
    • 5634 MIHP Action Plan -Spanish 
    • 5634 MIHP Action Plan-Arabic  

    Safety Plans

    • 5633 MIHP Safety Plan 
    • 5633 MIHP Safety Plan - Spanish  
    • 5633 MIHP Safety Plan-Arabic 

    Contact Log

    • 5649 Contact Log 

    Notification of Multiple Open Charts

    • 5704 Notification of Multiple Open Charts  

    ASQ-3 and ASQ:SE-2 Tracking for Multiples

    • 5714 Infant ASQ-3 and ASQ:SE-2 Tracking for Multiples 

    Infant Discharge Visit and Discharge Summary 

    • 5955 Discharge Visit - New! For services on or after October 1, 2024
    • Infant Discharge Summary Screenshot