Cycle 10

Action Plan

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

Care Coordination

• Care Coordination (MDHHS-5957) - instructions updated 1/26

Consent Forms

• Consent to Participate (MDHHS-5652) - instructions updated 12/25
  • Arabic
  • Spanish

• Consent to Release Protected Health Information (MDHHS-5645) - instructions updated 6/25
  • 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) 
• Maternal Discharge Summary - begin using paper form on 9/25/26 for input into MCCP starting 10/1/26
• Maternal Discharge Summary Screenshot (legacy system) 

Forms Checklist

• Maternal Forms Checklist (MDHHS-5701) -instructions updated 1/26
• Maternal Forms Checklist for Transfer Received (MDHHS-5708) - updated 10/25

Notification and Communication

• Maternal Prenatal Communication (MDHHS-5639) -updated 10/25
• Beneficiary Status Notification (MDHHS-5640) -updated 10/25
• Medicaid Health Plan Communication Tool (MDHHS-5650) - updated 6/26
• Medicaid Health Plan Communication Tool (Excel) - updated 5/26
• Transfer Fax Cover Sheet (MDHHS-5783) 

Notification of Multiple Open Charts

• Notification of Multiple Open Charts (MDHHS-5704) 

Plan of Care 1

• Maternal Plan of Care, Part 1 (MDHHS-5642)         
  • 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 

*POC 2 Crosswalk: Alignment with New Health Assessment (Updated 10/30/2026): For use starting 9/25/26 to assist with Domain Name changes as part of MCCP transition.

• Abuse/Violence (MDHHS-5665)
• Alcohol (MDHHS-5632)
• Breastfeeding (MDHHS-5663)
• Family Planning (MDHHS-5667)
• Food and Nutrition (MDHHS-5670)
• Housing (MDHHS-5669)
• Medical Considerations (MDHHS-5666)
• Pregnancy Health (MDHHS-5673)
• Preventing Adverse Childhood Experiences (PACEs)(MDHHS-6211)  
• Social Support (MDHHS-5672)
• Stress and Depression (MDHHS-5674)
• Substance Misuse (MDHHS-5631) 
• Tobacco (MDHHS-5630)
• Transportation (MDHHS-5675) 

Plan of Care 3

• Plan of Care Part 3 (MDHHS-5676) - instructions updated 10/26

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

• Maternal Professional Visit Progress Note (MDHHS-5636)  - updated 10/30/26
• IBCLC Professional Visit Progress Note (MDHHS-5641) 

Rights as an MIHP Participant

• Your Rights and Responsibilities as an MIHP Participant (MDHHS-5707)
  • Arabic
  • Spanish  

Risk Identifier (Beginning 9/25/26 Health Assessment)

• Pregnancy Health Assessment - begin using paper form on 9/25/26 for input into MCCP starting 10/1/26
• Pregnancy Health Assessment Guidance 
• Maternal Risk Identifier Worksheet (legacy system)
• Maternal Risk Identifier - Instructions (legacy system)
• Maternal Risk Identifier - Algorithm (legacy system)

Safety Plan

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

Archived Maternal Forms: Cycle 9

• Forms changes for Cycle 9

Consent Forms

• 5652 Maternal Consent to Participate  
• 5652 Maternal Consent to Participate - Arabic Version  
• 5652 Maternal Consent to Participate - Spanish Version
• 5645 Maternal Consent to Release Protected Health Information
• 5645 Maternal Consent to Release Protected Health Information - Arabic Version
• 5645 Maternal Consent to Release Protected Health Information - Spanish Version
• 5646 Consent to Transfer
• 5646 Consent to Transfer - Arabic Version
• 5646 Consent to Transfer - Spanish Version 

Risk Identifiers, Instructions, Algorithm 

• Maternal Risk Identifier Worksheet  
• Maternal Risk Identifier - Instructions
• Maternal Risk Identifier - Algorithm

Plans of Care

• 5642 Maternal Plan of Care Part 1  
• Plan of Care Part 1-Lead Fact Sheet - Spanish  
• 5665 Maternal Plan of Care Part 2 - Abuse Violence 
• 5632 Maternal Plan of Care Part 2 - Alcohol  
• 5663 Maternal Plan of Care Part 2 - Breastfeeding
• 5667 Maternal Plan of Care Part 2 - Family Planning
• 5670 Maternal Plan of Care Part 2 - Food and Nutrition
• 5669 Maternal Plan of Care Part 2 - Housing
• 5666 Maternal Plan of Care Part 2 - Medical Considerations
• 5673 Maternal Plan of Care Part 2 - Pregnancy Health
• 5672 Maternal Plan of Care Part 2 - Social Support
• 5674 Maternal Plan of Care Part 2 - Stress and Depression
• 5631 Maternal Plan of Care Part 2 - Substance Misuse
• 5630 Maternal Plan of Care Part 2 - Tobacco
• 5675 Maternal Plan of Care Part 2 - Transportation
• 5676 Plan of Care Part 3 - Signature Sheet for Interventions by Risk Level

Professional Visit Progress Notes

• 5636 Maternal 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

• 5639 Maternal Prenatal Communication 
• 5640  Beneficiary Status Notification 
• 5650 MHP (Word) Communication Tool
• 5650 MHP (Excel) Communication Tool updated 6.28.22 
• 5783  Transfer Fax Cover Sheet 

Maternal Forms Checklist

• 5701 Maternal Forms Checklist 
• 5708 Maternal 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 

Maternal Discharge Visit and Discharge Summary 

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