Healthcare Documents

This document is a legal advance directive that meets Wisconsin, Minnesota, and Iowa requirements. It allows you to name a health care agent and outline your medical care preferences. Make sure to review, discuss, and distribute it to relevant parties after completion.

The Lilly Cares Foundation offers a program to help patients obtain certain Eli Lilly medications at no cost. This application is for applying to receive these medications. Find information on eligibility, medications, and the application process.

This document provides a comprehensive standard plan of treatment for Palmetto infusion orders, including patient information, prescribed medications, and necessary guidelines. It also includes the required documentation for referrals and insurance verification information. It is essential for ensuring proper treatment and compliance with medical and insurance guidelines.

The Maryland Health Connection Affidavit of No Current Income is a form for individuals without income. It includes reasons for a lack of income and necessary certifications. Completing this form helps determine eligibility for Medicaid or a Qualified Health Plan.

This file is a log sheet for recording the usage and quality control of CIDEX OPA solution. It includes fields for test strip bottle opening date, QC test results, and more. It helps ensure compliance with usage guidelines.

This document is used by healthcare providers to prescribe medically necessary formulas and nutritional prescriptions for infants and children under the WIC program in Illinois. It must be completed fully and accurately to ensure proper nutritional support for the patient. The form includes sections for patient information, prescribed formula, food prescription, diagnosis, and healthcare provider details.

This document outlines the coaching practice policies, confidentiality guidelines, and informed consent for coaching and consultation services provided by Dr. Christy Vidrine Bauman, LMHC, MDFT. It includes detailed information regarding appointments, cancellations, social media policies, electronic communication, and termination of services. Additionally, it addresses the coaching process, confidentiality limits, and required disclosures.

The FP92A form is used to apply for a prescription charge exemption due to medical conditions. The patient fills Part 1 and Part 2, and the doctor completes Part 3. The completed form is sent to NHS Business Services Authority.

This form helps applicants determine if they qualify for long-term care services through Louisiana Medicaid. It is designed for those residing or planning to reside in nursing facilities, group homes, developmental centers, or those offered opportunities through HCBS or PACE. Detailed instructions and assistance contacts are provided.

The Abnormal Involuntary Movement Scale (AIMS) is used to assess involuntary movements. It includes ratings for different body parts and instructions for use. The form is essential for monitoring patients under medication.

This file provides the Illinois Do Not Resuscitate (DNR)/Practitioner Orders for Life-Sustaining Treatment (POLST) form. It's a voluntary form for patients to record their medical treatment preferences. It includes sections for CPR, medical interventions, nutrition, and documentation of discussion.

This file is the FDA Form 3500, used for voluntary reporting of adverse events, product problems, and medication errors to the FDA. It collects detailed patient, product, and event information. Properly filling out this form helps ensure the FDA can evaluate and take action on safety issues.