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.

Fields marked with * are required.

Identification Information

*Institution/Provider Name:
*Department:
*Send to the Attention of:
*Phone No:
*Address:
*City:
*State:
*Zip:

Supplies

Quantity	Category	Physician Form Description	Form #
	ANTIBITOTIC RESISTANCE	Pediatric Antibiotic Pamphlet Patient educational handout describing appropriate antibiotic use for children	Z6130
		Adult Antibiotic Pamphlet Patient educational handout describing appropriate antibiotic use for adults	Z6628
		Viral Infection Checklist Patient educational handout with suggested home treatments for viral infections	Z6249
	CARDIOVASCULAR	Cholesterol Guidelines	Z5352
		Coronary Artery Disease Guidelines	X7085
		Heart Failure Guidelines	Z5328
		High Blood Pressure Guidelines	Z6350
	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	Z5417
		Behavioral Health Summary Communication Form Form to send referring providers a written summary of behavioral health consultations	Z5443
	DEPRESSION	Specialist Major Depression Guidelines	Z4741
		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
	HEALTH MANAGEMENT BROCHURES	BabyLink Program Brochure	Z4048
		Balanced Outlook Program Brochure	Z5472
		Breathe Easy Program Brochure	Z4286
		Diabetes Advantage Program Brochure	Z5340
		Heart Sense Program Brochure	Z3868
		Pain Solutions Program Brochure	Z5473
	PREVENTATIVE	Preventive Guidelines	Z4765
	RESPIRATORY	Asthma Diary Patient educational handout for tracking symptoms, medication usage, and peak flows	Z4763
		Asthma Guidelines	Z4690
		Asthma Self Management Plan Patient educational handout providing suggested actions based upon symptoms and peak flows	Z4742
		COPD Guidelines	Z4837
		COPD Self Management Plan Patient educational handout providing suggested actions based upon symptoms	Z5286
		Tobacco Dependence Guidelines	Z5331
		Tobacco Dependence Information Sheet Patient educational handout with facts about tobacco	Z5509
		Tobacco Dependence Rx Pad Patient educational handout recommending smoking cessation with a list of available resources	Z5480
		Tobacco Use Chart Stick-ons Office identification stickers for medical records	Z5315

Coming In 2008

Secure Online Provider Portal
Electronic Funds Transfer
Electronic Remittance Advice

You've asked and we've listened! Learn More about new features and functionality coming to your provider website!

Learn More

Online Services

Emdeon Office

Access patient claim status, eligibility, benefits information and more.

Enroll in Emdeon Office

ReviewLink

Submit online prior approval requests for acute inpatient, skilled nursing facility and inpatient rehabilitation admissions. Access Smartsheets and submit requests for outpatient imaging services.

Visit ReviewLink

Find a Provider

Maximize your cost savings and avoid unexpected charges by finding providers in the Medical Mutual network.

Find a Provider

Featured Content

Access exclusive health and wellness information and tools from Medical Mutual and the world's premier online source... WebMD.

Report Fraud

Fraud detection has saved Medical Mutual members $58 million since 1983. If you suspect fraud, Medical Mutual wants to know.

Report Fraud

MedMutual.com | Providers Main | Become a Network Provider

Tools & Resources | Forms | Products & Services | Healthy Patients

ABOUT SSL CERTIFICATES

This Medical Mutual of Ohio Web site contains links to Web sites operated by third parties who are not under the control of Medical Mutual of Ohio or its affiliates and subsidiaries. Medical Mutual of Ohio disclaims all liability with regard to the information presented on these Web sites as well as your access to such linked Web sites. Medical Mutual of Ohio provides links to other sites as a service to users, and access to any other sites linked to Medical Mutual of Ohio is at your own risk.