CRMC Forms | Coffee Regional Medical Center CRMC Forms 912.384.1900 911 FOR EMERGENCIES FORMS Below are the most current forms referring physician offices should use for CRMC services and admissions. Please dispose of any other copies of these forms you may have. Physician Confidentiality Agreement Click Here for the Physician Confidentiality Agreement This form should be signed by all physicians and office staff using Mckesson Paragon Clinician Hub and OneContent (HPF) to acknowledge the use and privacy of Protected Health Information (PHI). Individual Confidentiality Agreement Click Here for the Individual Confidentiality Agreement . This form should be signed by all individuals representing an organization that needs to access Coffee Regional Medical Center’s EMR using Horizon Patient Folder and Physician Webstation to acknowledge the use and privacy of Protected Health Information (PHI) CRMC Admission Packet Click Here for the CRMC Admission Packet . This form should be completed and sent with every patient directed to the Hospital for admission or services. Admission Forms: Admission Order Form Adult Admission Check-list & Packet Admission Order Form Pediatric 09_12_25 Severe_Sepsis_Septic_Shock Adult Pneumonia Orders ASU Packet ASU Labs and Diagnostic test 04292024 Chest Pain Unstable Angina Myocardial Infarction Orders Congestive Heart Failure Orders Cardiology / Cardiopulmonary Forms: Outpatient Procedure Cardiac Cath PCI CRTD or ICD Checklist 02022025 Heart & Vascular Out-Patient Orders Outpatient Procedure Cardiac Cath PCI Cardiopulmonary Outpatient Orders Outpatient IV Therapy Forms: Bamlanivimab Packet Blood_Blood_Product_Transfusion Outpatient Intravenous and Injection Therapy Prolia DENOSUMAB Injection Protocol Fact Sheet for LAGEVRIO Fact-Sheet-for-PAXLOVID Molnupiravir Guidelines for OutPatient Prescribing Monoclonal Antibody (Mab) Protocol Orders Out Pt Use Paxlovid Guidelines for OutPatient Prescribing Tepezza Protocol for Out Pt Infusion Out Pt ENDOSCOPY Orders Radiology Forms: CT Scan Ordering Guide PET Scan Patient Instructions PET CT Prior Authorization Form Diagnostic Imaging Order Form Diagnostic Imaging Patient Instructions Imaging For Women Order Form Low Dose CT order Surgical / Procedure Forms: Hip Packet Knee Packet Spine Packet Shoulder Packet Pre−Surgery Patient−Reported Functional Assessment Spine Pre-Surgery Patient−Reported Functional Assessment Knee Pre−Surgery Patient−Reported Functional Assessment Shoulder Pre−Surgery Patient−Reported Functional Assessment Hip Case Request-Universal 04292024 Consent to Surgical or Diagnostic Procedure Consent to Surgical or Diagnostic Procedure Span Outpatient Procedure Surgery H & P Stop Bang Questionnaire Lab Forms: Histology Request Medical Cytology request Outpatient Lab test request OB GYN Lab Test request OB & WHS Forms: C Section Admin 07.11.2023 OB Admit 01.16.2024 OB Hyperemesis Admission 1/16/2023 Routine TAH_LAVH PreOp Orders Referral Forms: Congestive Heart Failure Referral Form Pain Clinic Referral Interventional Pain Procedures for Imaging Services Referral Cardiac Rehab Referral Form 05-2021 Referral for Rehabilitation Services Healthy Life Clinic Form – Medication Therapy Review Diabetes Resources: Diabetes Education OP-DSME-T-OP 03-2019 Diabetes Self-Assessment for Patients 03-2019 Resources If you have any questions about using these forms, don’t hesitate to contact the admissions office at CRMC (912) 384-1900 Ext-4549. 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