All Cycle 10 forms are considered final and posted below.

Cycle 10 Summary of Changes

• The Cycle 10 Summary of Changes document provides a high-level overview of Cycle 10 document updates.

Action Plan

• MIHP Action Plan (MDHHS-5634)  
  
  • Arabic
  • Spanish 

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

• Infant ASQ-3 and ASQ:SE-2 Tracking for Multiples (MDHHS-5714) - no changes from Cycle 9

Care Coordination

• Care Coordination (Enhanced Services) (MDHHS-5957) - no changes from Cycle 9

Consent Forms

• Consent to Participate (MDHHS-5647)
  • Arabic 
  • Spanish

• Consent to Release Protected Health Information (MDHHS-5653) - Instructions updated 6-2025
  • Arabic
  • Spanish

• Consent to Transfer (MDHHS-5646)
  • Arabic
  • Spanish

• Consent to Release Substance Use Treatment Records (MDHHS-5515)
  • All languages located at the link above.
  • See MIHP Operations Guide for guidance.

Contact Log

• Contact Log (MDHHS-5649)

Discharge Visit and Discharge Summary 

• Discharge Visit (MDHHS-5955) - no changes from Cycle 9
• Infant Discharge Summary Screenshot

Forms Checklist

• Infant Forms Checklist (MDHHS-5700)
• Infant Forms Checklist for Transfer Received (MDHHS-5699) - Updated 7-2025

Notification and Communication

• Infant Care Communication (MDHHS-5638) - updated 7-2025
• Beneficiary Status Notification (MDHHS-5640) - instructions change only
• Medicaid Health Plan Communication Tool (MDHHS-5650) (Word) - no changes from Cycle 9
• Transfer Fax Cover Sheet (MDHHS-5783) - no changes from Cycle 9

Notification of Multiple Open Charts

• Notification of Multiple Open Charts (MDHHS-5704) - no changes from Cycle 9

Plan of Care 1 

• Infant Plan of Care Part 1 (MDHHS-5637) - updated 7-2025
  • Lead Fact Sheet - See Parent/Family Resources
  • Immunization Fact Sheet - See Parent/Family Resources
  • Education Packet and Phone Apps - See Parent/Family Resources

Plans of Care 2

• Breastfeeding (MDHHS-5690)*
• Family and Social Support (MDHHS-5694)*
• Feeding (MDHHS-5693)*
• General Infant Development (MDHHS-5691)*
• Infant Health Care (MDHHS-5692)*
• Infant Safety (MDHHS-5695)*
• Preventing Adverse Childhood Experiences (PACEs)(MDHHS-6210)
• Substance Exposed Infant (MDHHS-5696)
• Transportation (MDHHS-5989)*

* Indicates POC 2s with updates made only to the Instructions page.

Plan of Care 3

• Plan of Care Part 3 (MDHHS-5676)  

Plan of Safe Care

• MIHP Plan of Safe Care (MDHHS-6173)
  • Arabic
  • Spanish

For additional resources and support: MIHP Plan of Safe Care Website

Professional Visit Progress Notes

• Infant Professional Visit Progress Note (MDHHS-5635)
• IBCLC Professional Visit Progress Note (MDHHS-5641) - no changes from Cycle 9

Rights as an MIHP Participant

• Your Rights and Responsibilities as an MIHP Participant (MDHHS-5707) - no changes from Cycle 9
  • Arabic
  • Spanish

  Risk Identifier, Instructions, Algorithm 

  • Infant Risk Identifier - Worksheet - no changes from Cycle 9
  • Infant Risk Identifier - Instructions - no changes from Cycle 9
  • Infant Risk Identifier - Algorithm - no changes from Cycle 9

  Safety Plan

  • MIHP Safety Plan (MDHHS-5633)
    • Arabic
    • Spanish

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