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.

Consent Forms - Pending

• 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 

• Consent to Exchange Substance Use Treatment Records
  • All languages located here: Michigan Behavioral Health Standard Consent Form
  • See MIHP Operations Guide for guidance

Risk Identifier, Instructions, Algorithm 

• Infant Risk Identifier - Worksheet  
• Infant Risk Identifier - Instructions  
• Infant Risk Identifier - Algorithm 

Plans of Care - Pending

• 5637 Infant Plan of Care Part 1
  • Lead Fact Sheet - See Parent/Family Resources
  • Immunization Fact Sheet - See Parent/Family Resources
  • Education Packet and Phone Apps - See Parent/Family Resources 
• 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 - Pending

• 5635 Infant Professional Visit Progress Note 
• 5641 IBCLC Professional Visit Progress Note

Care Coordination

• 5957 Care Coordination (Enhanced Services) 

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 - Pending

• 5638 Infant Care Communication - Pending
• 5640 Beneficiary Status Notification - Pending
• 5650 MHP (Word) Communication Tool  
• 5783 Transfer Fax Cover Sheet  

Infant Forms Checklist - Pending

• 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 

Plan of Safe Care

• 6173 MIHP Plan of Safe Care
• 6173 MIHP Plan of Safe Care - Spanish
• 6173 MIHP Plan of Safe Care - Arabic
• For additional resources and support: MIHP Plan of Safe Care Website

Contact Log - Pending

• 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 
• Infant Discharge Summary Screenshot  

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