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 

Care Coordination

• Care Coordination (Enhanced Services)(MDHHS-5957) 

Consent Forms - Pending

• Consent to Participate (MDHHS-5652)
  • Arabic
  • Spanish

• Consent to Release Protected Health Information (MDHHS-5645)
  • Arabic
  • Spanish

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

• Consent to Exchange Substance Use Treatment Records (MDHHS-5515)
  • All languages located here: Michigan Behavioral Health Standard Consent Form
  • See MIHP Operations Guide for guidance 

Contact Log - Pending

• Contact Log (MDHHS-5649)

Discharge Visit and Discharge Summary 

• Discharge Visit (MDHHS-5955)
• Maternal Discharge Summary Screenshot 

Forms Checklist - Pending

• Maternal Forms Checklist (MDHHS-5701)
• Maternal Forms Checklist for Transfer Received (MDHHS-5708)

Notification and Communication

• Maternal Prenatal Communication (MDHHS-5639) - Pending
• Beneficiary Status Notification (MDHHS-5640) - Pending
• Medicaid Health Plan Communication Tool (MDHHS-5650)
• 5650 MHP (Excel) Communication Tool updated 6.28.22 
• 5783  Transfer Fax Cover Sheet 

Notification of Multiple Open Charts

• 5704 Notification of Multiple Open Charts 

Plan of Care 1 - Pending

• Maternal 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

Plans of Care 2 - Pending

• 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) 
• Social Support (MDHHS-5672)
• Stress and Depression (MDHHS-5674) 
• Substance Misuse (MDHHS-5631) 
• Tobacco (MDHHS-5630)
• Transportation (MDHHS-5675) 

Plan of Care 3 - Pending

• Plan of Care Part 3 (MDHHS-5676)
  • Signature Sheet for Interventions by Risk Level

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

Professional Visit Progress Notes - Pending

• Maternal Professional Visit Progress Note (MDHHS-5636) 
• IBCLC Professional Visit Progress Note (MDHHS-5641) 

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  

Risk Identifier

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

Safety Plan

• 5633 MIHP Safety Plan 
• 5633 MIHP Safety Plan - Spanish  
• 5633 MIHP Safety Plan - Arabic   

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