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MIHP Infant Forms
MIHP Infant Forms
Infant Forms by Cycle
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Cycle 10
Cycle 10 Summary of Changes
- The Cycle 10 Summary of Changes document provides a high-level overview of Cycle 10 document updates.
Action Plan
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 Release Protected Health Information (MDHHS-5653) - Instructions updated 6-2025
- Consent to Release Substance Use Treatment Records (MDHHS-5515)
- All languages located at the link above.
- See MIHP Operations Guide for guidance.
Contact Log
Discharge Visit and Discharge Summary
- Discharge Visit (MDHHS-5955) - no changes from Cycle 9
- Infant Discharge Summary Screenshot
Forms Checklist
Notification and Communication
- Infant Care Communication (MDHHS-5638)
- 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)
- 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 Safe Care
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
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
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Cycle 9
Infant Forms: 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
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
Action Plans
Safety Plans
Contact Log
Notification of Multiple Open Charts
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