Posting in Progress

Cycle 10 forms are undergoing finalization. Once available, they will be linked below. Please see the updated Cycle 10 Operations Guide and the Summary of Changes document below for more information on document updates.

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 - pending
  • Spanish - pending

• Consent to Release Protected Health Information (MDHHS-5653)
  • Arabic - pending
  • Spanish - pending

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

• 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)

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 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