|
|
Item
Number
|
Description
|
Price
|
Unit
|
| |
48F-CHJ-101 |
POST ANESTHESIA CARE,DWH FORM |
$0.06 |
ST |
| |
48F-CHJ-102 |
SPECIAL NEEDS IDENT. SCREENING |
$2.96 |
PD |
| |
48F-CHJ-103 |
INFO CONCERNING SURGICAL REM. OF TEETH |
$0.06 |
ST |
| |
48F-CHJ-104 |
ANESTHESIA RECORD |
$0.04 |
ST |
| |
48F-CHJ-105 |
MEDICATION RECORD |
$2.56 |
PD |
| |
48F-CHJ-106 |
INTAKE HEALTH APPRAISAL-PHYS EXAM, |
$2.36 |
PD |
| |
48F-CHJ-108 |
DISCHARGE INSTRUCTIONS, |
$0.07 |
ST |
| |
48F-CHJ-109 |
INTAKE HISTORY/SCREENING |
$2.96 |
PD |
| |
48F-CHJ-110 |
MEDICAL HISTORY & PHYSICAL EXAM, |
$2.56 |
PD |
| |
48F-CHJ-111 |
NURSING CARE PLAN |
$0.10 |
EA |
| |
48F-CHJ-113 |
NUTRITIONAL ASSESSMENT |
$2.56 |
PD |
| |
48F-CHJ-114 |
ANNUAL HEALTH SCREENING |
$2.36 |
PD |
| |
48F-CHJ-115 |
DENTAL HEALTH HISTORY |
$2.76 |
PD |
| |
48F-CHJ-116 |
NURSING OPERATION ROOM RECORD |
$0.06 |
ST |
| |
48F-CHJ-117 |
CONSENT FOR PATIENT PHOTOGRAPH |
$2.36 |
PD |
| |
48F-CHJ-118 |
TISSUE EXAMINATION REQUEST |
$1.08 |
PD |
| |
48F-CHJ-120 |
PATIENT CARE FLOWSHEET |
$2.96 |
PD |
| |
48F-CHJ-121 |
PATIENT AUTHORIZATION DIS. HEALTH |
$2.96 |
PD |
| |
48F-CHJ-122 |
PHYSICIAN'S ORDER(CHX-122) |
$0.20 |
EA |
| |
48F-CHJ-123 |
FACE SHEET |
$2.36 |
PD |
| |
48F-CHJ-124 |
REDUCED CUSTODY PSYCH. SCREENING |
$0.10 |
ST |
| |
48F-CHJ-125 |
RADIOLOGY REQUEST AND REPORT |
$0.10 |
ST |
| |
48F-CHJ-126 |
RECEIPT OF HEALTH RECORD INFO. |
$2.36 |
PD |
| |
48F-CHJ-127 |
CERTIFICATE OF HEALTH RECORD |
$2.36 |
PD |
| |
48F-CHJ-128 |
PHYSICAL THERAPY |
$2.96 |
PD |
| |
48F-CHJ-129 |
PATIENT CONTRACT |
$0.06 |
ST |
| |
48F-CHJ-130 |
PROGRESS NOTES |
$2.96 |
PD |
| |
48F-CHJ-131 |
OUTPATIENT MEDICATION-PROOF OF USE |
$2.96 |
PD |
| |
48F-CHJ-132 |
FOOD ACCEPTANCE RECORD |
$2.36 |
PD |
| |
48F-CHJ-134 |
INH FLOW SHEET |
$2.56 |
PD |
| |
48F-CHJ-137 |
EMERGENCY TREATMENT W/PERF |
$0.06 |
ST |
| |
48F-CHJ-138 |
EMERGENCY TREATMENT-CONT. PAGE |
$0.07 |
ST |
| |
48F-CHJ-139 |
GRAPHIC CHART |
$2.56 |
PD |
| |
48F-CHJ-140 |
GENERAL FLOW SHEET |
$2.56 |
PD |
| |
48F-CHJ-141 |
HEALTH REVIEW FOR MDOC TRANSFER, |
$0.07 |
ST |
| |
48F-CHJ-143 |
INPATIENT SUMMARY |
$2.36 |
PD |
| |
48F-CHJ-144 |
EMERGENCY TRANSFER RECORD |
$0.07 |
ST |
| |
48F-CHJ-146 |
DENTAL TREATMENT |
$2.96 |
PD |
| |
48F-CHJ-147 |
RELEASE FROM RESPONSIBILITY |
$0.07 |
ST |
| |
48F-CHJ-148 |
INFO RELEASED FROM THIS HEALTH RECORD |
$2.56 |
PD |
| |
48F-CHJ-149 |
CONSENT TO SURGERY, ANE.MED TREAT. |
$0.06 |
ST |
| |
48F-CHJ-151 |
URINALYSIS - LAB REPORT |
$0.06 |
ST |
| |
48F-CHJ-155 |
PATIENT RIGHT CONSENT TREATMENT |
$2.56 |
PD |
| |
48F-CHJ-156 |
A HEALTHY WAY TO A HEALTHY WGT. |
$0.99 |
BK |
| |
48F-CHJ-157 |
CONSENT OF TREATMENT |
$0.06 |
ST |
| |
48F-CHJ-158 |
INTAKE AND OUTPUT RECORD |
$2.96 |
PD |
| |
48F-CHJ-159 |
PSYCHIATRIC TREATMENT MIS.REVIEW |
$0.06 |
ST |
| |
48F-CHJ-160 |
PROBLEM LIST,2 HOLE TOP PUNCH |
$0.04 |
EA |
| |
48F-CHJ-161 |
OFF-SITE HEALTH CARE ENCOUNTER |
$0.06 |
ST |
| |
48F-CHJ-162 |
REQUEST FOR OFF SITE HEALTH CARE |
$0.07 |
ST |
| |
48F-CHJ-163 |
TREATMENT PLAN MDOC |
$2.96 |
PD |
| |
48F-CHJ-164 |
CERTIFICATION PHYSICAL EXAMINATION |
$2.36 |
PD |
| |
48F-CHJ-166 |
NURSING HISTORY & ASSESSMENT PG 1&2 |
$2.96 |
PD |
| |
48F-CHJ-167 |
NURSING HISTORY & ASSESSMENT PG 3&4 |
$2.96 |
PD |
| |
48F-CHJ-168 |
PSYCHIATRIC ASSESSMENT -DISCHARGE |
$2.36 |
PD |
| |
48F-CHJ-169 |
INPATIENT SCREENING, |
$2.96 |
PD |
| |
48F-CHJ-171 |
PSYCHOLOGICAL REPORT-PG.1 |
$0.07 |
ST |
| |
48F-CHJ-172 |
PSYCHOLOGICAL REPORT PG.2 |
$0.07 |
ST |
| |
48F-CHJ-173 |
DIET HISTORY/NUTRITIONAL EVALUATION |
$2.96 |
PD |
| |
48F-CHJ-174 |
CONSENT OF CONTRAST INJEC. OF TREAT |
$0.06 |
ST |
| |
48F-CHJ-175 |
PSYCHIATRIC MEDICATIONS-SIDE EFFECTS |
$2.56 |
PD |
| |
48F-CHJ-177 |
MENTAL HEALTH MANAGEMENT RECOMMENDATION |
$0.10 |
ST |
| |
48F-CHJ-178 |
ATTORNEY COVER LETTER |
$2.36 |
PD |
| |
48F-CHJ-179 |
SUICIDE PREVENTION SCREENING |
$0.07 |
ST |
| |
48F-CHJ-180 |
EVALUATION OF SUICIDE RISK PRISONERS |
$2.36 |
PD |
| |
48F-CHJ-181 |
ADMISSION CONSENT FORM |
$0.09 |
ST |
| |
48F-CHJ-183 |
OFF-FORMULARY DRUG REQUEST |
$2.36 |
PD |
| |
48F-CHJ-184 |
ABNORMAL INVOLUNTARY MOVE. SC.-AIM |
$2.96 |
PD |
| |
48F-CHJ-185 |
SOCIAL ASSESSMENT |
$2.96 |
PD |
| |
48F-CHJ-189 |
HYPERSENSITIVITY REPORT |
$2.56 |
PD |
| |
48F-CHJ-190 |
PRE-NATAL RECORD |
$2.56 |
PD |
| |
48F-CHJ-191 |
HEALTH HISTORY-OBSTETRIC |
$2.36 |
PD |
| |
48F-CHJ-192 |
NURSING ORIENTATION (4 PGS) |
$10.24 |
PD |
| |
48F-CHJ-193 |
NURSING APPRAISAL-WEEKLY PERF. EVAL |
$2.36 |
PD |
| |
48F-CHJ-194 |
MENTAL HEALTH RECORD-DATA ENTRY REV |
$0.06 |
ST |
| |
48F-CHJ-195 |
MENTAL HEALTH NURSING CARE PLAN-CONT PG |
$2.56 |
PD |
| |
48F-CHJ-196 |
MEDICAL RECORD DEFICIENCY SLIP |
$0.04 |
ST |
| |
48F-CHJ-198- |
RECORD OF ON-CALL CONTACT |
$2.96 |
PD |
| |
48F-CHJ-199 |
MENTAL HEALTH SUMMARY SHEET |
$2.36 |
PD |
| |
48F-CHJ-200 |
OPTOMETRIC/VISION SCREENING |
$2.96 |
PD |
| |
48F-CHJ-200A |
OPTHALMIC PROGRESS NOTES |
$2.96 |
PD |
| |
48F-CHJ-201 |
OPHTHALMIC EVALUATION |
$2.96 |
PD |
| |
48F-CHJ-204 |
RESTRAINT SECLUSION F&B |
$3.35 |
PD |
| |
48F-CHJ-206 |
RESTRAINT MONITORING FLOW SHEET |
$2.36 |
PD |
| |
48F-CHJ-207 |
ACTIVITY PARTICIPATION RECORD |
$2.56 |
PD |
| |
48F-CHJ-208 |
INFORMATION & CONSENT FOR EPINEPHRINE IN |
$2.36 |
PD |
| |
48F-CHJ-209 |
CERTIFICATION WHEN NO INFORMED CONSENT. |
$2.36 |
PD |
| |
48F-CHJ-210 |
INPATIENT RECORD LOCATOR |
$2.36 |
PD |
| |
48F-CHJ-211 |
PERSONAL GROOMING FLOW SHEET |
$2.56 |
PD |
| |
48F-CHJ-213 |
ACTIVITY ASSESSMENT F&B |
$2.96 |
PD |
| |
48F-CHJ-214 |
SEGREGATION DETENTION ROUNDS |
$2.96 |
PD |
| |
48F-CHJ-215 |
PRE-NATAL EDUCATION RECORD PG 1 & 2 |
$2.56 |
PD |
| |
48F-CHJ-216 |
PRE-NATAL EDUCATION RECORD PG 3 |
$2.36 |
PD |
| |
48F-CHJ-217 |
CONSENT TO ROUTINE NON-SURG.MED |
$0.07 |
ST |
| |
48F-CHJ-218 |
TRANSFER ASSESSMENT SCREENING |
$2.96 |
PD |
| |
48F-CHJ-219 |
MENTAL HEALTH KARDEX |
$0.07 |
EA |
| |
48F-CHJ-220 |
MENTAL HEALTH KARDEX-MED. INSERT |
$0.01 |
EA |
| |
48F-CHJ-221 |
PSYCHOLOGICAL SCREENING -PG.1 & 2 |
$2.56 |
PD |
| |
48F-CHJ-222 |
PSYCHOLOGICAL SCREENING PG-3 |
$2.36 |
PD |
| |
48F-CHJ-223- |
CONFIDENTIAL/PRIVILEGED COMM. |
$2.56 |
PD |
| |
48F-CHJ-224 |
AGE APPROPRIATE PREVENTION SERVICES |
$0.06 |
EA |
| |
48F-CHJ-225 |
HIV COUNSELING NEGATIVE RESULTS REV |
$0.06 |
ST |
| |
48F-CHJ-227 |
AMENDMENT OF HEALTH RECORD.DOC. |
$2.36 |
PD |
| |
48F-CHJ-228 |
MENTALLY ILL DISCHARGE/TRANSFER TRACKING |
$2.36 |
PD |
| |
48F-CHJ-229 |
FACSIMILE COVER LETTER |
$2.36 |
PD |
| |
48F-CHJ-230 |
DURABLE POWER OF ATTORNEY FOR HEALTH CAR |
$0.07 |
BK |
| |
48F-CHJ-233 |
DURABLE POWER OF ATT F/HEALTH CARE-PG 1 |
$0.06 |
ST |
| |
48F-CHJ-234 |
DURABLE POWER OF ATT F/HEALTH CARE-PG 2 |
$0.06 |
ST |
| |
48F-CHJ-235 |
DURABLE POWER OF ATT F/HEATLH CARE-PG 3 |
$0.06 |
ST |
| |
48F-CHJ-236 |
ACCEPTANCE OF PATIENT AD.DESG.PG1 |
$0.06 |
ST |
| |
48F-CHJ-237 |
ACCEPTANCE/PATIENT AD. DESGN. PG2 |
$0.07 |
ST |
| |
48F-CHJ-238 |
CRISIS STABILIZATION UNIT REFERRAL |
$2.56 |
PD |
| |
48F-CHJ-239 |
COMBINED POINT OF ENTRY & ARRIVAL SCREEN |
$2.36 |
PD |
| |
48F-CHJ-240 |
CERTIFICATE OF DESTRUCTION |
$2.36 |
PD |
| |
48F-CHJ-241 |
COUNTY TO STATE MEDICAL TRANSFER RECORD |
$0.06 |
ST |
| |
48F-CHJ-242 |
CSU INITIAL ASSESSMENT/TREATMENT PLAN |
$2.56 |
PD |
| |
48F-CHJ-243 |
TUBERCULOSIS SUMMARY RECORD |
$2.36 |
PD |
| |
48F-CHJ-244 |
SPECIAL ACCOMMODATION NOTICE |
$0.12 |
ST |
| |
48F-CHJ-245 |
EMPLOYEE TB SCREENING PROGRAM |
$2.36 |
PD |
| |
48F-CHJ-246 |
MENTAL HEALTH REFERRAL/EVAL-DATA ENTRY |
$2.36 |
PD |
| |
48F-CHJ-247 |
OUTPATIENT PRE-OP ASSESSMENT, |
$2.36 |
PD |
| |
48F-CHJ-248 |
NIDDM EDUCATION STANDARDS |
$2.96 |
PD |
| |
48F-CHJ-249 |
CONFIDENTIALITY STATEMENT |
$2.36 |
EA |
| |
48F-CHJ-250 |
GENERAL FLOW SHEET-B |
$0.04 |
SH |
| |
48F-CHJ-251 |
NOTICE OF SEX OFFENDER PROGRAM SCREENING |
$0.10 |
ST |
| |
48F-CHJ-254 |
MEDICATION TEACHING |
$2.36 |
PD |
| |
48F-CHJ-255 |
PATIENT TEACHING |
$2.36 |
PD |
| |
48F-CHJ-256 |
IMMUNIZATIONS |
$2.36 |
PD |
| |
48F-CHJ-257 |
INPATIENT MEDICATION ADMIN RECORD |
$2.56 |
PD |
| |
48F-CHJ-258 |
DAILY NURSING ASSESSMENT & CARE R. |
$2.56 |
PD |
| |
48F-CHJ-259 |
NURSING PATIENT CARE PLAN, |
$2.56 |
PD |
| |
48F-CHJ-260 |
FALL RISK EVALUATION SHEET |
$2.36 |
PD |
| |
48F-CHJ-261 |
NURSING ADMISSION (3 PGS), |
$4.93 |
PD |
| |
48F-CHJ-263 |
HEPATITIS B VACCINATION DECLINATION-EMPL |
$2.36 |
PD |
| |
48F-CHJ-264 |
MEDICAL OPINION FOR HEP B VACCINE-EMPL |
$2.36 |
PD |
| |
48F-CHJ-265 |
HEPATITIS B VACCINATION-PRISONER, |
$2.96 |
PD |
| |
48F-CHJ-267 |
HEALTH CARE CONTACT WORKSHEET, |
$2.36 |
PD |
| |
48F-CHJ-268 |
RESPONSE TO REQUEST HEALTH RECORD |
$0.06 |
ST |
| |
48F-CHJ-269 |
Electronic Form Only |
$0.06 |
ST |
| |
48F-CHJ-270 |
T.B. SYMPTOMS-HEALTH SCREENING QUESTIONN |
$2.56 |
PD |
| |
48F-CHJ-271 |
PULMONARY CLINIC FLOWSHEET |
$2.36 |
PD |
| |
48F-CHJ-272- |
PULMONARY CLINIC DATABASE |
$0.05 |
ST |
| |
48F-CHJ-274- |
NEUROLOGY CLINIC DATABASE |
$0.06 |
ST |
| |
48F-CHJ-275 |
DIABETIC CLINIC FLOWSHEET |
$2.36 |
PD |
| |
48F-CHJ-276- |
ENDOCRINE CLINIC DATABASE |
$0.06 |
ST |
| |
48F-CHJ-277 |
GASTROINTESTINAL CLINIC FLOWSHEET |
$2.36 |
PD |
| |
48F-CHJ-278- |
GASTROINTESTINAL CLINIC DATABASE |
$0.06 |
ST |
| |
48F-CHJ-279 |
CARDIAC/HYPERTENSION CLINIC F-SHEET |
$2.36 |
PD |
| |
48F-CHJ-280- |
CARDIAC/HYPERTENSION CLINIC DATABASE |
$0.06 |
ST |
| |
48F-CHJ-283 |
INFECTIOUS DISEASE CLINIC FLOWSHEET |
$2.36 |
PD |
| |
48F-CHJ-284- |
INFECTIOUS DISEASE CLINIC DATABASE |
$0.06 |
ST |
| |
48F-CHJ-288 |
INTRA-INSTITUTIONAL TRANSFER LOG,2-SIDED |
$3.77 |
BK |
| |
48F-CHJ-289- |
URGENT/EMERGENCY LOG |
$4.93 |
PK |
| |
48F-CHJ-290 |
GRIEVANCE LOG |
$3.77 |
BK |
| |
48F-CHJ-293- |
Specialty/Referral Log |
$4.60 |
PK |
| |
48F-CHJ-294. |
KITE LOG |
$4.93 |
PK |
| |
48F-CHJ-295- |
LABORATORY LOG |
$4.93 |
PK |
| |
48F-CHJ-296- |
MEDICATION LOG F&B |
$4.93 |
PK |
| |
48F-CHJ-297- |
AMBULATORY CLINIC APPOINTMENTS |
$4.93 |
PK |
| |
48F-CHJ-298 |
TELEMEDICINE LOG(PK OF 200 SH) |
$3.94 |
PK |
| |
48F-CHJ-300 |
PSYCHIATRIC REPORT-PROPOSED PLAN |
$2.36 |
PD |
| |
48F-CHJ-301 |
NOTICE OF INTENT TO TERMINATE FORMAL VOL |
$0.07 |
ST |
| |
48F-CHJ-302 |
PHYSICIAN'S CERTIFICATE |
$2.56 |
PD |
| |
48F-CHJ-303 |
EDUCATIONAL ASSESSMENT |
$2.56 |
PD |
| |
48F-CHJ-304 |
TREATMENT PLAN REVIEW |
$2.56 |
PD |
| |
48F-CHJ-305 |
NURSING ADMISSION ASSESSMENT (4 PGS) |
$5.52 |
PD |
| |
48F-CHJ-306 |
Electronic Form Only |
$6.99 |
PD |
| |
48F-CHJ-307 |
COMPREHENSIVE PSYCHIATRIC EXAM. |
$2.56 |
PD |
| |
48F-CHJ-309 |
COMPREHENSIVE INDIVIDUAL TREATMENT |
$5.12 |
PD |
| |
48F-CHJ-310 |
COMPREHENSIVE INDIVIDUAL TREATMENT |
$2.96 |
PD |
| |
48F-CHJ-311 |
NOTICE OF HEARING-PA 252 |
$2.05 |
PD |
| |
48F-CHJ-312 |
PROOF OF SERVICE PA 252 |
$2.05 |
PD |
| |
48F-CHJ-314 |
WAIVER OF HEARING CONSENT T-MENT |
$2.05 |
PD |
| |
48F-CHJ-315 |
REPORT OF ORDER AND HEARING |
$2.05 |
PD |
| |
48F-CHJ-316 |
APPEAL OF HEARING COMMITTEE |
$2.05 |
PD |
| |
48F-CHJ-318 |
REQUEST FOR CONSULTATION WITH CORR. |
$2.36 |
ST |
| |
48F-CHJ-319 |
NOTICE OF OPPORTUNITY FOR HEARING, |
$2.05 |
PD |
| |
48F-CHJ-320 |
REPORT OF QMHP CONTINUING SERVICE |
$2.56 |
PD |
| |
48F-CHJ-321 |
ADMIS/RIGHT/CONSENT FOR MEN. HEAL. |
$2.56 |
PD |
| |
48F-CHJ-322 |
QMHP REPORT |
$2.36 |
PD |
| |
48F-CHJ-323 |
QMHP REPORT-CONTINUATION PAGE |
$2.36 |
PD |
| |
48F-CHJ-324 |
RELIGIOUS INTEREST QUESTIONNAIRE |
$2.56 |
PD |
| |
48F-CHJ-325 |
OUTPATIENT/RESIDENTIAL MENTAL HEALTH TRE |
$2.36 |
PD |
| |
48F-CHJ-332 |
MENTAL HEALTH EVALUATION/ADMISSION REFER |
$2.96 |
PD |
| |
48F-CHJ-335 |
CLOSE OBSERVATION FORM-100PD |
$3.35 |
PD |
| |
48F-CHJ-338 |
CAMP ARRIVAL SCREENING |
$2.96 |
PD |
| |
48F-CHJ-343 |
DURABLE MEDICAL EQUIPMENT CONTRACT |
$0.06 |
ST |
| |
48F-CHJ-401- |
OFFSITE INPATIENT LOG |
$4.93 |
PK |
| |
48F-CHJ-402 |
X-RAY LOG |
$4.93 |
PK |
| |
48F-CHJ-403 |
OBSERVATION LOG |
$3.77 |
BK |
| |
48F-CHJ-404 |
SELF ADMINISTERED MEDICATION RECORD |
$2.36 |
PD |
| |
48F-CHJ-406 |
DISCHARGE CHECKLIST |
$2.96 |
PD |
| |
48F-CHJ-407 |
CMS OUTPATIENT AUTHORIZATION REQUEST |
$2.96 |
PD |
| |
48F-CHJ-408 |
CMS DECISION FORM |
$2.96 |
PD |
| |
48F-CHJ-409 |
SPECIALTY CONSULT REPORT |
$2.96 |
PD |
| |
48F-CHJ-416 |
TUBERCULOSIS SYMPTOMS/HEALTH SCREENING |
$2.56 |
PD |
| |
48F-CHJ-418 |
TUBERCULOSIS SUMMARY RECORD-PRISONERS |
$2.36 |
PD |
| |
48F-CHJ-423 |
TREATMENT PLAN-DIABETES |
$2.96 |
PD |
| |
48F-CHJ-424 |
TREATMENT PLAN-SEIZURE DISORDER |
$2.96 |
PD |
| |
48F-CHJ-425 |
TREATMENT PLAN-CARDIOVASCULAR DISEASE |
$2.96 |
PD |
| |
48F-CHJ-426 |
TREATMENT PLAN-GASTROINTESTINAL DISEASE |
$2.96 |
PD |
| |
48F-CHJ-427 |
TREATMENT PLAN-INFECTIOUS DISEASE |
$2.96 |
PD |
| |
48F-CHJ-428 |
TREATMENT PLAN-PULMONARY DISEASE |
$2.96 |
PD |
| |
48F-CHJ-434 |
CLINIC FLOWSHEET DIAGNOSIS 100/PD |
$2.36 |
PD |
| |
48F-CHJ-437 |
DISCHARGE PLAN-TB |
$0.07 |
ST |
| |
48F-CHJ-446 |
GUIDELINES FOR UNIVERSAL/STANDARD PRECAU |
$0.05 |
ST |
| |
48F-CHJ-447 |
GUIDELINES/UNIVERSAL STAND PRECAUTIONS |
$0.06 |
ST |
| |
48F-CHJ-449 |
DENTAL EXAM & TREATMENT |
$2.96 |
PD |
| |
48F-CHJ-450 |
COMMUNITY HEALTH CARE REFERRAL |
$0.12 |
ST |
| |
48F-CHJ-451 |
RESPONSIBILITY DETERMINATION-REIMBURSMEN |
$0.07 |
ST |
| |
48F-CHJ-452 |
INFLUENZA VACCINE CONSENT |
$2.36 |
PD |
| |
48F-CHJ-459 |
Photo Copy only form |
$0.01 |
EA |
| |
48F-CHJ-461 |
HEPATITIS A VACCINATION |
$2.36 |
PD |
| |
48F-CHJ-464 |
INTAKE SCREENING/HISTORY OF SEXUAL ABUSE |
$2.96 |
PD |
| |
48F-CHJ-465 |
HIV POSITIVE POST-TEXT COUNSELING |
$0.07 |
ST |
| |
48F-CHJ-470 |
DENTAL INTAKE EXAMINATION |
$2.96 |
PD |
| |
48F-CHJ-500 |
HEALTH RECORDS FOR TRANSFER, |
$0.06 |
ST |
| |
48F-CHJ-501 |
ON-SITE INPATIENT LOG, |
$2.36 |
PD |
| |
48F-CHJ-502 |
PHYSICAL THERAPY DETAIL REQUEST |
$1.18 |
PD |
| |
48F-CHJ-503 |
PRISONER REQUEST FOR HEALTH REC.LOG |
$2.36 |
PD |
| |
48F-CHJ-504 |
SPECIALITY CLINIC REPORT |
$2.36 |
PD |
| |
48F-CHJ-505 |
MEDICATION INCIDENT |
$0.10 |
ST |
| |
48F-CHJ-506- |
ADVERSE DRUG REACTION |
$0.07 |
ST |
| |
48F-CHJ-507 |
DAILY CENSUS SHEET |
$2.36 |
PD |
| |
48F-CHJ-508 |
REPORT OF PATIENT CONDITION NURSING. |
$2.76 |
PD |
| |
48F-CHJ-509 |
X-RAY FILE CARD |
$0.01 |
EA |
| |
48F-CHJ-511 |
APPOINTMENT CARD |
$0.01 |
EA |
| |
48F-CHJ-512 |
PROPERTY RELEASE |
$1.18 |
PD |
| |
48F-CHJ-513 |
YOU AND YOUR TEETH |
$2.36 |
PD |
| |
48F-CHJ-515 |
DAILY NON-COMPLIANCE RECORD |
$0.06 |
ST |
| |
48F-CHJ-516 |
LAUNDRY ROSTER |
$0.06 |
ST |
| |
48F-CHJ-517 |
MEAL REQUEST (2 SEP FORMS) |
$2.56 |
PD |
| |
48F-CHJ-518 |
EYEGLASS PRESCRIPTION, |
$1.19 |
PD |
| |
48F-CHJ-519 |
HOSPITAL ADMITTING SLIP, |
$0.01 |
ST |
| |
48F-CHJ-520 |
PATIENT INDEX CARD |
$0.01 |
EA |
| |
48F-CHJ-521 |
MEDICATION CARD - T.I.D. |
$0.05 |
EA |
| |
48F-CHJ-522 |
MEDICATION CARD-BID |
$0.04 |
EA |
| |
48F-CHJ-523 |
MEDICATION CARD-HS, |
$0.04 |
EA |
| |
48F-CHJ-524 |
MEDICATION CARD-QID |
$0.04 |
EA |
| |
48F-CHJ-525 |
MEDICATION CARD-DAILY |
$0.04 |
EA |
| |
48F-CHJ-528 |
ARCHIVE LOCATOR CARD |
$0.01 |
EA |
| |
48F-CHJ-529 |
MENTAL HEALTH INPATIENT PROGRAM NOTES |
$0.04 |
SH |
| |
48F-CHJ-530 |
NOTICE OF MENTAL HEALTH SERVICES, |
$0.12 |
ST |
| |
48F-CHJ-531 |
PRE-ADMISSION AND DISCHARGE ROOM CHECK |
$2.36 |
PD |
| |
48F-CHJ-533 |
DENTAL MONTHLY REVIEW |
$2.96 |
PD |
| |
48F-CHJ-534 |
DENTAL DAILY REPORT |
$2.96 |
PD |
| |
48F-CHJ-535 |
DAILY CENSUS |
$2.36 |
PD |
| |
48F-CHJ-536 |
ADMITTANCE AND DISCHARGE REPORT |
$1.18 |
PD |
| |
48F-CHJ-537 |
THIS FORM IS PHOTOCOPY ONLY |
CALL * |
PD |
| |
48F-CHJ-538-A |
CHRONIC CARE FLOWSHEET |
$0.06 |
ST |
| |
48F-CHJ-538-B |
CHRONIC CARE CLINIC FOLLOW UP FORM |
$0.06 |
ST |
| |
48F-CHJ-539 |
PROSTHETICS PRESCRIPTION -CAMPS |
$0.04 |
ST |
| |
48F-CHJ-540 |
NARCOTICS COUNT REGISTER |
$2.36 |
PD |
| |
48F-CHJ-541 |
INPATIENT CONSULTATION REQUEST/REPORT |
$0.06 |
ST |
| |
48F-CHJ-542 |
INFIRMARY WORK SHEET |
$3.94 |
PD |
| |
48F-CHJ-543 |
MENTAL HEALTH PROGRESS NOTES |
$2.36 |
PD |
| |
48F-CHJ-544 |
DENTAL PROSTHETIC, |
$0.10 |
ST |
| |
48F-CHJ-545 |
PATIENT INDEX CARDS |
$0.01 |
EA |
| |
48F-CHJ-546 |
FULL DENTURES |
$1.18 |
PD |
| |
48F-CHJ-547 |
NOTIFICATION TO HEALTH CARE OF PROPOSED |
$2.36 |
PD |
| |
48F-CHJ-549 |
HEALTH CARE REQUEST, W/PERF |
$0.11 |
ST |
| |
48F-CHJ-550 |
CASE MANAGEMENT |
$0.07 |
ST |
| |
48F-CHJ-551 |
SEGREGATION PSYCHOLOGICAL SCREENING |
$0.06 |
ST |
| |
48F-CHJ-552 |
CLINIC CALL OUT LIST |
$0.07 |
ST |
| |
48F-CHJ-553 |
INFECTION SURVEILLANCE MONTHLY REVIEW |
$0.05 |
SH |
| |
48F-CHJ-556 |
MEDICAL DETAIL |
$0.12 |
ST |
| |
48F-CHJ-558 |
X-RAY FILE CARD IONIA ADDRESS |
$0.01 |
EA |
| |
48F-CHJ-559 |
DIABETIC FLOWSHEET |
$2.56 |
PD |
| |
48F-CHJ-560- |
RELEASE FROM RESPONSIBILITY/CARDIOVASCUL |
$0.06 |
ST |
| |
48F-CHJ-562 |
RELEASE FROM RESPONSIBILITY/ENDOCRINE |
$0.06 |
ST |
| |
48F-CHJ-563 |
TREATMENT MANAGEMENT REC. AFTERCARE |
$2.36 |
PD |
| |
48F-CHJ-564 |
RELEASE FROM RESPONSIBILITY/GASTROINTEST |
$0.06 |
ST |
| |
48F-CHJ-565 |
SEIZURE REPORT |
$2.36 |
PD |
| |
48F-CHJ-567 |
MEDICAL CARE EVALUATION-ADULT CRITERIA-1 |
$2.36 |
PD |
| |
48F-CHJ-568 |
MEDICAL CARE EVALUATION-AUDIT CRITERIA-2 |
$2.36 |
PD |
| |
48F-CHJ-569 |
MEDICAL CARE EVALUATION-AUDIT CRITERIA-3 |
$2.36 |
PD |
| |
48F-CHJ-570 |
MEDICAL CARE EVALUATION-AUDIT CRITERIA-4 |
$2.36 |
PD |
| |
48F-CHJ-571 |
MEDICAL CARE EVALUATION-AUDIT CRITERIA-5 |
$2.36 |
PD |
| |
48F-CHJ-575 |
PRISONER INSURANCE INFORMATION |
$2.96 |
PD |
| |
48F-CHJ-576 |
IMMUNIZATION RECORD & CONSENT |
$2.36 |
PD |
| |
48F-CHJ-577 |
PERMISSION FOR DENTAL TREATMENT |
$0.06 |
ST |
| |
48F-CHJ-579- |
DENTAL PROSTHETICS LOG (200 P/PACK) |
$4.93 |
PK |
| |
48F-CHJ-580- |
DENTAL KITE LOG (200 P/PACK) |
$4.93 |
PK |
| |
48F-CHJ-581- |
DENTAL DAILY LOG (200 P/PACK) |
$4.93 |
PK |
| |
48F-CHJ-582 |
DENTAL INSTRUMENT INVENTORY LOG BOOK |
$4.93 |
PK |
| |
48F-CHJ-583 |
DENTAL NEEDLE INVENTORY LOG |
$0.01 |
SH |
| |
48F-CHJ-584 |
DENTAL BLADE INVENTORY LOG |
$0.01 |
SH |
| |
48F-CHJ-585 |
DENTAL OFFSITE REFERRAL LOG(200 SH/BOOK) |
$0.01 |
SH |
| |
48F-CHJ-587 |
BIOLOGICAL MONITORING F/STEAM STERILIZER |
$0.01 |
SH |
| |
48F-CHJ-588 |
RELEASE FROM RESPONSIBILITY/INFECTIOUS |
$0.06 |
ST |
| |
48F-CHJ-589 |
RELEASE FROM RESPONSIBILITY/PULMONARY |
$0.06 |
ST |
| |
48F-CHJ-590 |
RELEASE FROM RESPONSIBILITY/NEUROLOGY |
$0.06 |
ST |
| |
48F-CHJ-591 |
DISABILITY CLINIC FLOWSHEET |
$2.96 |
PD |
| |
48F-CHJ-592 |
COMPREHENSIVE INDIVIDUAL TREATMENT ETC. |
$2.06 |
PD |
| |
48F-CHJ-594 |
MENTAL HEALTH ANNUAL ASESSMENT/REV ETC |
$2.06 |
PD |
| |
48F-CHJ-595 |
OUTPATIENT ADMISSION ASSESSMENT |
$2.06 |
PD |
| |
48F-CHJ-601 |
DISABILITY CLINIC DATABASE |
$2.96 |
PD |
| |
48F-CHJ-602 |
DIABILITY CHRONIC CARE/FOLLOW-UP |
$2.96 |
PD |
| |
48F-CHJ-603- |
PULMONARY CRONIC CARE CLINIC FOLLOW-UP |
$0.06 |
ST |
| |
48F-CHJ-604- |
ENDOCRINE CHRONIC CARE CLINIC FOLLOW UP |
$0.06 |
ST |
| |
48F-CHJ-605- |
GASTROINTESTINAL CHRONIC CARE CLINIC |
$0.06 |
ST |
| |
48F-CHJ-606- |
CARDIOVASCULAR CHRONIC CARE CLINIC |
$0.06 |
ST |
| |
48F-CHJ-607- |
INFECTIOUS DISEASE CHRONIC CARE CLINIC |
$0.06 |
ST |
| |
48F-CHJ-608- |
NEUROLOGIC CHRONIC CARE CLINIC FOLLOWUP |
$0.06 |
ST |
| |
48F-CHJ-624 |
PRISONER MEDICAL REORDER FORM |
$0.07 |
ST |
| |
48F-CHJ-626 |
PRE RELEASE ALT TESTING |
$0.06 |
ST |
| |
48F-CHJ-630 |
HEPATITIS C-POSITIVE POST TEST COUNSELIN |
$0.07 |
ST |
| |
48F-CHJ-631 |
HEPATITIS C-NEGATIVE POST TEST COUNSELIN |
$0.07 |
ST |
| |
48F-CHJ-639 |
VIRAL HEPATITIS CLINIC DATABASE |
$0.06 |
ST |
| |
48F-CHJ-640 |
VIRAL HEPATITIS CHRONIC CARE CLINIC |
$0.06 |
ST |
| |
48F-CHJ-643 |
PAIN MANAGEMENT COMMITTEE PATIENT HISTOR |
$2.96 |
PD |
| |
48F-CHJ-644a |
PAIN MGMT COMMITTEE PAIN ASSESS - PG1-2 |
$2.96 |
PD |
| |
48F-CHJ-644b |
PAIN MGMT COMMITTEE PAIN ASSESS - PG3-4 |
$2.96 |
PD |
| |
48F-CHJ-645-1 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 1 |
$2.36 |
PD |
| |
48F-CHJ-645-10 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 10 |
$2.36 |
PD |
| |
48F-CHJ-645-2 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 2 |
$2.36 |
PD |
| |
48F-CHJ-645-3 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 3 |
$2.36 |
PD |
| |
48F-CHJ-645-4 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 4 |
$2.36 |
PD |
| |
48F-CHJ-645-5 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 5 |
$2.36 |
PD |
| |
48F-CHJ-645-6 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 6 |
$2.36 |
PD |
| |
48F-CHJ-645-7 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 7 |
$2.36 |
PD |
| |
48F-CHJ-645-8 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 8 |
$2.36 |
PD |
| |
48F-CHJ-645-9 |
PAIN MGMT COMMITTEE PHYSICAL EXAM-PG 9 |
$2.36 |
PD |
| |
48F-CHJ-646 |
DIAGNOSTIC TESTING RESULT NOTIFICATION |
$0.06 |
ST |
| |
48F-CHJ-654 |
EMERGENCY TREATMENT MEDICAL MSP,DWH FORM |
$0.06 |
ST |
| |
48F-CHJ-657 |
Health Work Assignment Clearance |
$0.14 |
ST |
| |
48F-CHJ-658 |
PHYSICIAN ORDERS F/LIFE SUSTAINING TREAT |
$0.14 |
ST |
| |
48F-CHJ-803 |
DMB or DCH makes this form |
$1.30 |
BK |
| |
48F-CHJ-804 |
INMATE INFECTION CONTROL |
$0.15 |
EA |