PROVIDER HOME TOOLS & RESOURCES FORMS NETWORK PROVIDER FORMS CLINICAL SUPPLY FORM

Clinical Quality Supply Requisition Form

To order supplies, please fill the form out below and submit.

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Identification Information

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Supplies

Quantity	Category	Physician Form Description	View Form
	ANTIBITOTIC RESISTANCE	Pediatric Antibiotic Pamphlet Patient educational handout describing appropriate antibiotic use for children	Z7191
		Adult Antibiotic Pamphlet Patient educational handout describing appropriate antibiotic use for adults	Z7199
		Viral Infection Checklist Patient educational handout with suggested home treatments for viral infections	Z7089
	CARDIOVASCULAR	Cholesterol Guidelines	Z5352
		Coronary Artery Disease Guidelines	X7085
		Heart Failure Guidelines	Z5328
		High Blood Pressure Guidelines	Z6350
		Managing High Blood Pressure Patient educational booklet with facts and recommendations	Z7224
		DASH to a Lower Blood Pressure Patient educational booklet with facts and recommendations	Z7223
	CHRONIC PAIN	Musculoskeletal & Chronic Pain Guidelines	X6195
	CONTINUITY	Continuity and Coordination of Medical Care Standards for timely written communication between referring and consulting physicians	X7059
		Behavioral Health Continuity of Care Guidelines Standards for timely written communications from consulting behavioral health clinicians to referring providers	X5825
		Patient Summary Physician Communication Form Form for documenting necessary clinical information when requesting a consultation	Z7134
		Behavioral Health Summary Communication Form Form to send referring providers a written summary of behavioral health consultations	Z5443
	DEPRESSION	Specialist Major Depression Guidelines	Z4741
	DEPRESSION		Primary Care Physician Major Depression Guidelines	Z4819
		Antidepressant Card Educational card mailed to patients starting on an antidepressant to promote compliance and proper follow-up	Z5361
		Depression and Alcohol Screening Provider educational handout regarding standardized depression and alcohol screening tools	Z6591
	DIABETES	Diabetes Mellitus Guidelines	Z4744
		Diabetic Eye Examination Report Form for provider to provider communication regarding diabetic eye exam requests and results	Z7075
		ABC's of Diabetes Tests and Targets Card Patient educational booklet with facts and recommendations	Z7207
		Eye Care Card Patient educational booklet with facts and recommendations	Z7324
	DISEASE AND MATERNITY MANAGEMENT	SuperWell® Disease and Maternity Management Program Brochure	Z7325
	PREVENTATIVE	Preventive Guidelines	Z4765
	RESPIRATORY	Asthma Diary Patient educational handout for tracking symptoms, medication usage, and peak flows	Z7193
		Asthma Guidelines	Z4690
		Asthma Self Management Plan Patient educational handout providing suggested actions based upon symptoms and peak flows	Z7194
		COPD Guidelines	Z4837
		COPD Self Management Plan Patient educational handout providing suggested actions based upon symptoms	Z7195
		Tobacco Dependence Guidelines	Z5331
		Tobacco Dependence Information Sheet Patient educational handout with facts about tobacco	Z7205
		Tobacco Dependence Rx Pad Patient educational handout recommending smoking cessation with a list of available resources	Z7206
		Tobacco Use Chart Stick-ons Office identification stickers for medical records	Z7204

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