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MIHP Maternal Forms
MIHP Maternal Forms
Maternal Forms by Cycle
-
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
Care Coordination
- Care Coordination (Enhanced Services) (MDHHS-5957) - no changes from Cycle 9
Consent Forms
- Consent to Release Protected Health Information (MDHHS-5645) - Instructions updated 6-2025
- Arabic - pending
- 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
Discharge Visit and Discharge Summary
- Discharge Visit (MDHHS-5955) - no changes from Cycle 9
- Maternal Discharge Summary Screenshot
Forms Checklist
Notification and Communication
- Maternal Prenatal Communication (MDHHS-5639)
- Beneficiary Status Notification (MDHHS-5640) - instructions change only
- Medicaid Health Plan Communication Tool (MDHHS-5650) - no changes from Cycle 9
- Medicaid Health Plan Communication Tool (MDHHS-5650) (Excel) - 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
- 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*
- 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)
- For additional resources and support: MIHP PACEs Website
- Social Support (MDHHS-5672)*
- Stress and Depression (MDHHS-5674)*
- Substance Misuse (MDHHS-5631)
- Tobacco (MDHHS-5630)*
- Transportation (MDHHS-5675)*
* indicates POC2s that incurred an update 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
- Maternal Professional Visit Progress Note (MDHHS-5636)
- 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
- Maternal Risk Identifier Worksheet- no changes from Cycle 9
- Maternal Risk Identifier - Instructions - no changes from Cycle 9
- Maternal Risk Identifier - Algorithm - no changes from Cycle 9
Safety Plan
-
Cycle 9
Maternal Forms: 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
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
Action Plans
Safety Plans
Contact Log
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