UCAOA Policy & Procedure Manual 2017 Edition. Table of Contents

UCAOA Policy & Procedure Manual 2017 Edition 100.XXX Administration Table of Contents 1. 100.XXX- Advanced Beneficiary Notice (ABN) English Version 2020 Large Print 2. 100.XXX- Advanced Beneficiary Notice (ABN) English Version 2020 3. 100.XXX- ABN Spanish Version 2020 Large Print 4. 100.XXX- Absent Medical Provider 5. 100.XXX- Abuse Neglect Overview or Reporting Responsibilities 6. 100.XXX- Abuse Neglect Violence State Reporting 7. 100.XXX- Abuse Reporting- Child/ Elderly Abuse Reporting 8. 100.XXX- Abuse Child Report or Neglect 9. 100.XXX- Advanced Beneficiary Notice (ABN) Form Instructions 10. 100.XXX- Advanced Beneficiary Notice 11. 100.XXX- Advance Directives Page 2 12. 100.XXX- Advance Directives Page 1 13. 100.XXX- Animal Bite Control Form- Oakland County (sample state or county specific) 14. 100.XXX- Animal Bite Reporting 15. 100.XXX- Animal Bite Reporting Guidelines Form- Louisiana (sample state or county specific) 16. 100.XXX- Animal Bites Reporting- Louisiana (sample state or county specific) 17. 100.XXX- Care Coordination Follow-Up PCP or Referring Physician 18. 100.XXX- Care Coordination Follow-Up Doc 19. 100.XXX- Care Coordination Referral Letter 20. 100.XXX- Care Coordination Sample Cover Letter PCP 21. 100.XXX- Collection Log Front Desk 22. 100.XXX- Consent In Office Procedure Form 23. 100.XXX- Disruption of Information Process 24. 100.XXX- Established Patient Intake Form 25. 100.XXX- Flag System Form 26. 100.XXX- Flag System- Managing Patient Flow 27. 100.XXX- Front Desk- Influenza Vaccine Consent 28. 100.XXX- Front Desk- Occ Med Acknowledgment of Responsibility for Charges for Workers Comp 29. 100.XXX- Front Desk- Auto Accident Claim Processing- UC 30. 100.XXX- Front Desk- Auto Acknowledgement of Responsibility for Charges 31. 100.XXX- Front Desk -Billing- Global Periods 32. 100.XXX- Front Desk- Billing- Recheck Policy 33. 100.XXX- Front Desk- Cash Pay Flu Shot- Patient Information Sheet 34. 100.XXX- Front Desk- Cash Drawer Log 35. 100.XXX- Front Desk-Chief Complaint /Consent for Treatment- Louisiana 36. 100.XXX- Front Desk- Consent for Treatment & Use of Disclosure of Protected Health Info Form 37. 100.XXX- Consent to Release of Information 38. 100.XXX- Front Desk- Customer Service Encounter

39. 100.XXX- Front Desk- Established Patient Information Short Form 40. 100.XXX- Front Desk- Established Patient Update Form 41. 100.XXX- Front Desk- External Referrals or Service Options 42. 100.XXX- Front Desk Form- for Consent and Chief Complaints 43. 100.XXX- Front Desk Form - Employee Discount Request Form 44. 100.XXX- Front Desk Form- for Notice of Receipt of Privacy 45. 100.XXX- Front Desk Form- Patient Registration 46. 100.XXX- Front Desk Form- Payment Policies 47. 100.XXX- Front Desk Form- Practice to Release Private Health Information to Third Parties 48. 100.XXX- Front Desk Form- Supplemental Claims Information 49. 100.XXX- Front Desk- Forms Request- Completion of Forms 50. 100.XXX- Front Desk- Influenza Vaccine Cash Pay Form 51. 100.XXX- Front Desk- Log Collections 52. 100.XXX- Front Desk- Log Patient Registration 53. 100.XXX- Front Desk- Medical Treatment Discount 54. 100.XXX- Front Desk- Medical Treatment Discount- Discounted Services 55. 100.XXX- Front Desk- Missing Router 56. 100.XXX- Front Desk- Occ Med Employer Authorization Form 57. 100.XXX- Front Desk- Occ Med Medical Record Form 58. 100.XXX- Front Desk- Occ Med Patient Form 59. 100.XXX- Front Desk- Occ Med Patient Registration Form 60. 100.XXX- Front Desk- Occ Med Work Status Form 61. 100.XXX- Front Desk- Occ Med Worker Intake Form 62. 100.XXX- Front Desk- Patient Call Back Forms 63. 100.XXX- Front Desk- Patient Check Out 64. 100.XXX- Front Desk- Patient Identifiers 65. 100.XXX- Front Desk- Patient Information Sample Form 66. 100.XXX- Front Desk- Patient Payments 67. 100.XXX- Front Desk- Patient Presentation of Serious Illness or Injury 68. 100.XXX- Front Desk- Patient Registration 69. 100.XXX- Front Desk- Patient Information Consent Form 70. 100.XXX- Front Desk-Patient Identification 71. 100.XXX- Front Desk- Receipt of Privacy Documents Acknowledgement 72. 100.XXX- Front Desk- Time of Service Collections V.2 73. 100.XXX- Front Desk- Time of Service Collections 74. 100.XXX- Front Desk- Visit Policy 75. 100.XXX- Front Desk- Workers Compensation Claims Policy 76. 100.XXX- Front Desk- Workers Compensation Claims Processing 77. 100.XXX- Governance- Social Media 78. 100.XXX- Governance- Clinical Work Flow 79. 100.XXX- Governance- Corporate Spending Expense Report Sample 80. 100.XXX- Governance- Corporate Spending 81. 100.XXX- Governance- Employee Recognition Committee 82. 100.XXX- Governance- Finance Capitalization

83. 100.XXX- Governance- Management Leadership Competencies 84. 100.XXX- Governance- Mission Statement 85. 100.XXX- Governance- Mission and Core Values Statement 86. 100.XXX- Governance- Operations Committee Policy 87. 100.XXX- Governance- Organizational Chart- Leadership Sample 88. 100.XXX- Governance- Organizational Hierarchy and Clinical Staffing Model 89. 100.XXX- Governance Organization Meetings 90. 100.XXX- Governance- Organization Chart 91. 100.XXX- Governance- Purpose, Governance Policy 92. 100.XXX- Governance- Scope of Service and Population Served 93. 100.XXX- Governance- Scope of Services Policy 94. 100.XXX- Governance- Social Media Policy 95. 100.XXX- Identity Theft and Red Flag Rules 96. 100.XXX- Influenza Immunization Consent Form 97. 100.XXX- Informed Consent for Procedure Form 98. 100.XXX- Informed Consent for Procedure Information 99. 100.XXX- Interpretive Services and Communication Barriers 100. 100.XXX- Interpretive Services- Louisiana and Texas 101. 100.XXX- Minors Treatment- State Specific 102. 100.XXX- Non- Retaliation Policy 103. 100.XXX- Occ Med Audiometer Calibrations 104. 100.XXX- Occ Med Direct Billing Protocol Policy 105. 100.XXX- Occ Med End of Day Staff Activities 106. 100.XXX- Occ Med Pulmonary Function Testing Machine Calibrations 107. 100.XXX- Occ Med Respiratory Fit Test Machine Calibrations 108. 100.XXX- Opening and Closing Procedures with Checklist 109. 100.XXX- Patient Call Follow Up Contact 110. 100.XXX- Patient Intake Form 111. 100.XXX- Patient Rights and Ethical Care 112. 100.XXX- Patient Rights and Responsibilities Policy 113. 100.XXX- Patient Rights Specific Request Form 114. 100.XXX- Policy/ Procedure/ Forms Management 115. 100.XXX- Policy and Procedure Process 116. 100.XXX- Policy and Procedure Request 117. 100.XXX- Policy and Procedure Template 118. 100.XXX- Prescription Secure Handling 119. 100.XXX- Privacy Practices Acknowledgement Form 120. 100.XXX- Radiology Only Process 121. 100.XXX- Radiology Only Log 122. 100.XXX- Router Form 123. 100.XXX- Signature and Initial Sample Log 124. 100.XXX- Telephone Encounter 125. 100.XXX- Terminating a Patient from the Practice 126. 100.XXX- Unable to Reach Patient About Test Results

200.XXX- Human Resources, Orientation, Competencies, Credentialing 1. 200.XXX- Behavior of Employee 2. 200.XXX- Incident Reporting Employee Policy 3. 200.XXX- Peer Review- Medical Provider 4. 200.XXX- Absenteeism and Tardiness 5. 200.XXX- Absenteeism and Sick Leave 6. 200.XXX- ACLS Requirement and Training 7. 200.XXX- ACLS BLS PALS Training 8. 200.XXX- Annual Training and Review Checklist 9. 200.XXX- Annual Training 10. 200.XXX- Appointment Approval Sample Letter 11. 200.XXX- Appointment- Authorization to Release information 12. 200.XXX- Appointment- Authorization Release Form 13. 200.XXX- Appointment- Authorization Consent to Release of Information 14. 200.XXX- Appointment- Provider Checklist 15. 200.XXX- Appointment- Reappointment Application 16. 200.XXX- Background Checks 2 17. 200.XXX- Background Check Release Organization 18. 200.XXX- Background Checks 19. 200.XXX- Behavior- Discrimination/ Harassment 20. 200.XXX- Behavior- Patient Non- Discrimination 21. 200.XXX- BLS Requirement and Training 1 22. 200.XXX- BLS Requirement and Training 23. 200.XXX- Breaks and Meals 24. 200.XXX- Breaks 25. 200.XXX- Catheterization Straight Female 26. 200.XXX- Code of Conduct 27. 200.XXX- Competencies Annual Checklist 28. 200.XXX- Competencies 29. 200.XXX- Competency- Checklist New Hire 30. 200.XXX- Competency- Clean Catch 31. 200.XXX- Competency- Digital X-Ray Images 32. 200.XXX- Ear irrigation 33. 200.XXX- Competency- Injectable Medication 34. 200.XXX- Competency- Injection IM 35. 200.XXX- Competency- Injection Subcutaneous 36. 200.XXX- Competency- Specimen Labeling and Handling 37. 200.XXX- Competency- TB Mantoux Skin Test 38. 200.XXX- Competency- Tuberculin Skin Test Mantoux 39. 200.XXX- Competency- Vital Signs 40. 200.XXX- Complaint Form Employee 41. 200.XXX- Conflict of Interest Form Attachment 1

42. 200.XXX- Conflict of Interest Attachment 43. 200.XXX- Conflict of Interest Policy 44. 200.XXX- Conflict of Interest 45. 200.XXX-Credentialing Appeals Process 46. 200.XXX- Credentialing Disclosure Claims Information Form 47. 200.XXX- Credentialing of Providers 48. 200.XXX- Credentialing- Appointment/Reappointment 49. 200.XXX- Credentialing- Initial Verification Form 50. 200.XXX- Credentialing- License Insurance Verification 51. 200.XXX- Credentialing- Practitioner Profile for Appointment Cover Sheet 52. 200.XXX- Credentialing- Provider 53. 200.XXX- Credentialing- Release and Immunity- Initial Application 54. 200.XXX- Criminal Background Checks 55. 200.XXX- Cultural Diversity 56. 200.XXX- Cultural Awareness and Sensitivity Training 57. 200.XXX- Cultural Sensitivity 58. 200.XXX- Dress and Appearance 59. 200.XXX- Drug/Alcohol Free Environment 60. 200.XXX- Electronic Devices, Use of 61. 200.XXX- Employee Change Form 62. 200.XXX- Employee File Contents 63. 200.XXX- FMLA Disability Forms 64. 200.XXX- Hepatitis Vaccine for Employees 65. 200.XXX- Incident Employee Form 66. 200.XXX- Influenza Vaccination Program for Employees 67. 200.XXX- Job Description Template 68. 200.XXX- Job Description Policy 69. 200.XXX- License Verification-Non-Provider for Louisiana 70. 200.XXX- Medical Staff Appointment-Reappointment Application 71. 200.XXX- Medical Staff Approval of Appointment- Generic Letter 72. 200.XXX- Medical Staff Delineation of Privileges 73. 200.XXX- Non-Discrimination 74. 200.XXX- Onboarding Form- HIPAA Acknowledgement 75. 200.XXX- Onboarding Form- Hepatitis B Vaccination Election 76. 200.XXX- Onboarding I9 Form- Employment Eligibility Verification 77. 200.XXX- Onboarding Provider Checklist 78. 200.XXX- Orientation- and Training- New Hire 79. 200.XXX- Orientation- Checklist Pre-Patient Care 80. 200.XXX- Orientation- Billing Checklist 81. 200.XXX- Orientation- Clinical 82. 200.XXX- Orientation- Employee 83. 200.XXX- Orientation- Physician Checklist 84. 200.XXX- Orientation- Proficiency Requirements 85. 200.XXX- Orientation- Reception Checklist

86. 200.XXX- Peer Review Medical Provider Form 87. 200.XXX- Performance Appraisal Template 88. 200.XXX- Physician Insurance Check List 89. 200.XXX- Privacy Employee 90. 200.XXX- Privileges Delineation 91. 200.XXX- Proficiencies 92. 200.XXX- Reappointment- Release and Immunity 93. 200.XXX- Re-credentialing Verification Form 94. 200.XXX- Reimbursement-CME 95. 200.XXX- Roles and Responsibilities- Medical Director 96. 200.XXX- Scheduling Change Requests 97. 200.XXX- Scheduling Time Off- Holidays 98. 200.XXX- Scheduling Time Off- Provider 99. 200.XXX- Student Letter Sample 100. 200.XXX- Student Rotation or Shadowing Policy 101. 200.XXX- Student Shadowing Form 102. 200.XXX- Student Application 103. 200.XXX- Student Checklist 104. 200.XXX- Substance Use- Prohibited 105. 200.XXX- Supervision- Advanced Practice Clinicians 106. 200.XXX- Termination from Employment Form 107. 200.XXX- Termination Involuntary Form 108. 200.XXX- Time and Attendance 109. 200.XXX- Training- Annual Training Checklist 110. 200.XXX- Training Required 111. 200.XXX- Tuberculosis Annual Questionnaire 112. 200.XXX- Tuberculosis Testing- Employee 113. 200.XXX- Tuberculosis TST Questionnaire 114. 200.XXX- Vacation, Sick, Holiday Pay Eligibility 115. 200.XXX- Vehicle Use- Release of Driving Record Form 116. 200.XXX- Vehicle Use-Safety 117. 200.XXX- Video and Audio Recording 118. 200.XXX- Warning Form 300.XXX- Clinical, General, Occ Med 1. 300.XXX- Abuse and Assault Treatment 2. 300.XXX- Chaperones 3. 300.XXX- Consent- Informed 2 4. 300.XXX- Consent- Informed Form 5. 300.XXX- Consent- Informed 6. 300.XXX- Discharge Guidelines 7. 300.XXX- Discharge Instructions Policy

8. 300.XXX- Discharge Instructions Form Template 9. 300.XXX- Ear Irrigation 10. 300.XXX- Education- Patient and Family 11. 300.XXX- EKG Operation 12. 300.XXX- Emergency Situations 13. 300.XXX- Emergency Transfers 2 14. 300.XXX- Emergency Transfers Log 15. 300.XXX- Emergency Transfers Tracking Policy 16. 300.XXX- Emergency Transfers 17. 300.XXX- Emergency Staff Responsibility During Cardiac Arrest 18. 300.XXX- Eye Irrigation 19. 300.XXX- Fast Track Patient Assessment 20. 300.XXX- Fecal Specimen Collection 21. 300.XXX- Fecal Specimen 22. 300.XXX- Gait Training/Crutch Fitting 23. 300.XXX- Hard of Hearing Patient 24. 300.XXX- Hepatitis B Acknowledgement Form 25. 300.XXX- Identifiers- Patient 2 26. 300.XXX- Identifiers- Patient 27. 300.XXX- Nasal Specimen 28. 300.XXX- Occ Med- Breath Alcohol Testing 29. 300.XXX- Occ Med- Employers Authorization for Examination or Treatment 30. 300.XXX- Occ Med- Pre-Employment/Return to Work Clearance Form 31. 300.XXX- Occ Med- Pre-Placement Examination-Pre-Employment Return to Work Combo 32. 300.XXX- Occ Med- Return to Work Examination 33. 300.XXX- Occ Med- Audiometric Testing and Screening 34. 300.XXX- Occ Med- Breath Alcohol Test Checklist 35. 300.XXX- Occ Med- Breath Alcohol Testing 36. 300.XXX- Occ Med- DOT Physical Exam 2 37. 300.XXX- Occ Med- DOT Physical Exam 38. 300.XXX- Occ Med- Grip Strength Testing 39. 300.XXX- Occ Med- Physical- Return to Work 40. 300.XXX- Occ Med- Pre-Employment Return to Work Clearance Form 41. 300.XXX- Occ Med- Pre-Placement Exam and Physical Exam Form- Two Forms 42. 300.XXX- Occ Med- Pre-Placement Physical Policy 43. 300.XXX- Occ Med- Pre-Placement Physical 2 44. 300.XXX- Occ Med- Pre-Placement Physical 45. 300.XXX- Occ Med- Pulmonary Function Testing 46. 300.XXX- Occ Med- Respirator Fit Tests 47. 300.XXX- Occ Med- Vision Screening-Titmus Ishihara 48. 300.XXX- Orders- Standing 49. 300.XXX- Orders 50. 300.XXX- Oxygen Administration 51. 300.XXX- PCP Follow Up Letter- Rochester (sample)

52. 300.XXX- Pediatric Bulb Suctioning 53. 300.XXX- Pediatric Fever Control 54. 300.XXX- Pediatric IV Therapy 55. 300.XXX- Pelvic Exam 56. 300.XXX- Physical Examinations 57. 300.XXX- Physical- Return to Work 58. 300.XXX- Physical- Sports 59. 300.XXX- Physician Inquiries- Walk-in Established Patients 60. 300.XXX- Referral Letter 61. 300.XXX- Refusal of Care Against Medical Advice-Left Exam Room 62. 300.XXX- Refusal of Care AMA Acknowledgement 63. 300.XXX- Refusal of Care Form 2 64. 300.XXX- Refusal of Care- Left Without Being Seen 65. 300.XXX- Refusal of Care 66. 300.XXX- Refusal of Treatment- Attachment 67. 300.XXX- Return to Work- School Note 68. 300.XXX- Sports Physical Form from Michigan High School Athletic Association 69. 300.XXX- Suture/Staple Removal 70. 300.XXX- Td or Tdap Consent 71. 300.XXX- Telephone Advice 72. 300.XXX- Throat Specimen 73. 300.XXX- Triage Process- Check In 74. 300.XXX- Tuberculosis Skin Test Consent and Results 75. 300.XXX- Tuberculosis Test Consent and Results 76. 300.XXX- Tuberculosis Test Log 77. 300.XXX- Tuberculosis Positive Exempt Surveillance Questionnaire 78. 300.XXX- Tuberculosis Screening Mantoux 79. 300.XXX- Urine Collection- Female Catheter 80. 300.XXX- Urine Collection- Male Catheter 81. 300.XXX- Vaccine Influenza 82. 300.XXX- Vital Signs 2 Attachment 83. 300.XXX- Vital Signs 2 84. 300.XXX- Vital Signs- Pediatric 85. 300.XXX- Vital Signs 400.XXX- Medication 1. 400.XXX- Adverse Reactions Management 1 2. 400.XXX- Adverse Reactions Management 2 3. 400.XXX- Dispensed Medication Log 4. 400.XXX- Dispensing Practitioner- Point of Care Dispensing Indiana 5. 400.XXX- Expired Medication or Hazard Disposal Log 6. 400.XXX- Formulary- Annual Review

7. 400.XXX- Formulary- Approved 8. 400.XXX- Immunization Reporting State- Louisiana 9. 400.XXX- Influenza Control Log 10. 400.XXX- Influenza Immunization Sign in Sheet 11. 400.XXX- Influenza Immunization- CDC Patient Information 12. 400.XXX- Influenza Vaccine Immunization Administration 13. 400.XXX- IV- Adding Medication 14. 400.XXX- IV- Bolus 15. 400.XXX- IV- Discharging 16. 400.XXX- IV- Monitoring the Site 17. 400.XXX- IV- Push 18. 400.XXX- IV- Starting 19. 400.XXX- L.E.T. Application 20. 400.XXX- Medical Recall Log 21. 400.XXX- Medication Refrigerator- Temperature Check Graph 22. 400.XXX- Medication- Administration 2 23. 400.XXX- Medication- Administration Error 24. 400.XXX- Medication- Administration 25. 400.XXX- Medication- Disposal Log 26. 400.XXX- Medication- Expiration Date Audit 27. 400.XXX- Medication- Management Inspection Checklist 28. 400.XXX- Medication- Samples Log 2 29. 400.XXX- Medication- Tracking Form 30. 400.XXX- Medication- Alerts/Warnings 31. 400.XXX- Medication- Disposal Log 32. 400.XXX- Medication- Disposal 33. 400.XXX- Medication- Expired Log 34. 400.XXX- Medication- Injection Log 35. 400.XXX- Medication- Refrigerator Temperature 36. 400.XXX- Medication- Sample Receipt Log 37. 400.XXX- Medication- Samples Management 2 38. 400.XXX- Medication- Samples Management 39. 400.XXX- Medication- Samples Dispensed Log 40. 400.XXX- Medication- Samples Log 41. 400.XXX- Medication- Security Storage Disposal 42. 400.XXX- Medications and Dated Patient Items Review Log 43. 400.XXX- Narcotic Monitoring Daily Log 44. 400.XXX- Narcotic Controlled Substance Inventory Log 45. 400.XXX- Narcotic Controlled Substance Control 46. 400.XXX- Pharma Rep- Confidentiality Form 47. 400.XXX- Recall- Medication, Product, or Equipment 48. 400.XXX- Recall- Medication 49. 400.XXX- Request for New Medication or Service Policy 50. 400.XXX- Td or Tdap Consent

51. 400.XXX- Td or Tdap 52. 400.XXX- Td or Tdap CDC Informational Sheet 53. 400.XXX- Vaccine Encounter 54. 400.XXX- Vaccine Refrigerator/Freezer Temperature Log 55. 400.XXX- Vaccine Reporting Form 500.XXX- Laboratory 1. 500.XXX- Stool Collection Policy 2. 500.XXX- CLIA Waived Testing 3. 500.XXX- Competency- Fecal Occult Blood 4. 500.XXX- Competency- Glucometer 5. 500.XXX- Competency- hcg Urine Cassette Pregnancy Test 6. 500.XXX- Competency- Influenza A & B Test 7. 500.XXX- Competency- Mono Test 8. 500.XXX- Competency- Strep A Test 9. 500.XXX- Competency- Urinalysis 10. 500.XXX- Competency- Critical Test Results- After Hours 11. 500.XXX- Encounter Lab Only 12. 500.XXX- Glucometer 13. 500.XXX- Glucose Level Testing 14. 500.XXX- H. Pylori Testing 15. 500.XXX- Hemoccult 16. 500.XXX- HIV Testing 17. 500.XXX- Influenza Testing 18. 500.XXX- Influenza Molecular Testing 19. 500.XXX- Lab Courier Form 20. 500.XXX- Lab Environment Criteria 21. 500.XXX- Lab Ordering and Tracking Results 22. 500.XXX- Log- Glucometer 2 23. 500.XXX- Log- Glucometer 24. 500.XXX- Log- hcg 2 25. 500.XXX- Log- hcg 26. 500.XXX- Log- Hemoccult 2 27. 500.XXX- Log- Hemoccult 28. 500.XXX- Log- H. Pylori Control 29. 500.XXX- Log- Influenza AB 2 30. 500.XXX- Log- Influenza AB 31. 500.XXX- Log- Bab Daily Quality Controls 32. 500.XXX- Log- Mono Test 2 33. 500.XXX- Log- Mono Test 34. 500.XXX- Log- Room Temperature and Humidity 35. 500.XXX- Log- RSV

36. 500.XXX- Specimen Transport 37. 500.XXX- Log- Strep 2 38. 500.XXX- Log- Strep 39. 500.XXX- Log- Urine Analyzer Daily Maintenance 40. 500.XXX- Log- Urine Dipstick 41. 500.XXX- Manufacturer Package Inserts and Instructions 42. 500.XXX- Mono Test 43. 500.XXX- Non DOT Urine Drug Screen Collection 44. 500.XXX- Occ Med Drug Screen, DOT and Non- DOT Collection 45. 500.XXX- Patient Preparation 46. 500.XXX- Point of Care Testing and Results Reporting 47. 500.XXX- Pregnancy hcg 48. 500.XXX- Quality Controls 49. 500.XXX- Reagents- Lab 50. 500.XXX- Records Retention- Lab 51. 500.XXX- Refrigerator- Lab Specimen- Temperature Check Graph 52. 500.XXX- Room Temperature and Humidity 53. 500.XXX- RSV 54. 500.XXX- Safety Overview Lab 55. 500.XXX- Send Out Reference Lab Procedure 56. 500.XXX- Send Out Unable to Complete Test Procedures 57. 500.XXX- Specimen- Blood 58. 500.XXX- Specimen- Fasting 59. 500.XXX- Specimen- Identification 60. 500.XXX- Specimen- Preparation and Transport 61. 500.XXX- Specimen- Urine Clean Catch 62. 500.XXX- Specimen- Wound or Viral 63. 500.XXX- Specimen- Unacceptable 64. 500.XXX- Strep Testing 65. 500.XXX- Training- CLIA Waived Documentation 66. 500.XXX- Urinalysis Results Form 67. 500.XXX- Urinalysis Dipstick 2 68. 500.XXX- Urinalysis Dipstick 69. 500.XXX- Urine Drug Screen Affidavit of Correction (Memorandum for Record) 70. 500.XXX- Waived Testing Overview 600.XXX- Radiology 1. 600.XXX- Outside X-Ray Protocol 2. 600.XXX- Over-reads Process 3. 600.XXX- Over-reads 4. 600.XXX- Patient Log 5. 600.XXX- Pregnancy Consent Form

6. 600.XXX- Radiation Protection 7. 600.XXX- Radiation Discrepancy Policy 8. 600.XXX- Radiation Protection 9. 600.XXX- Radiology Read Discrepancy Log 10. 600.XXX- Radiology Safety 11. 600.XXX- Radiology Summary- Monthly 12. 600.XXX- Radiology Tracking Log 13. 600.XXX- Radiology Tracking 14. 600.XXX- Request for X-Ray 700.XXX- Infection Control 1. 700.XXX- Autoclave- Maintenance Monthly Log 2. 700.XXX- Autoclave- Maintenance 3. 700.XXX- Autoclave- Bio Monitoring Policy 2 4. 700.XXX- Autoclave- Bio Monitoring 5. 700.XXX- Autoclave- Bio Log 6. 700.XXX- Autoclave- Instruments 7. 700.XXX- Autoclave- Log 8. 700.XXX- Autoclave- Procedures 9. 700.XXX- Autoclave- Spore Checks 10. 700.XXX- Cleaning Responsibilities 11. 700.XXX- Communicable Disease Report Form 12. 700.XXX- Communicable Disease Reporting- Louisiana 13. 700.XXX- Communicable Disease Reporting- State Specific 14. 700.XXX- Daily Surface Disinfectant Log 15. 700.XXX- Exposure- Consent Form 16. 700.XXX- Exposure- Control Plan 17. 700.XXX- Exposure- Employee (Biological) 18. 700.XXX- Exposure- Follow Up Protocol 19. 700.XXX- Exposure- Incident Report 20. 700.XXX- Glove Use Audit 21. 700.XXX- Gloving Procedures- WHO Guidelines 22. 700.XXX- Hand Hygiene Policy 23. 700.XXX- Hand Hygiene- CDC 24. 700.XXX- HIV- Healthcare Workers- CDC 25. 700.XXX- Infection Control and Cleanliness Overview 26. 700.XXX- Infection Control- Annual Program Evaluation 27. 700.XXX- Infection Control- Sample Audit 28. 700.XXX- Infection Prevention and Control 29. 700.XXX- Infection Control- Annual- Infection Prevention and Control Surveillance Audit 30. 700.XXX- Infectious Disease- Emergency Response 31. 700.XXX- Infectious Disease Reporting Form

32. 700.XXX- Instruments- Reusable 33. 700.XXX- Personal Protective Equipment- OSHA- Fact Sheet 34. 700.XXX- Personal Protective Equipment- OSHA- Cuts Risk 35. 700.XXX- Reportable Conditions Example- State Specific Policy 36. 700.XXX- Sharps Bloodborne Fact Sheet- OSHA 37. 700.XXX- Sterile Field Preparation 38. 700.XXX- Tuberculosis Annual Screening Questionnaire 39. 700.XXX- Tuberculosis Annual Test Questionnaire 40. 700.XXX- Tuberculosis- Risk Reduction Plan- Louisiana 41. 700.XXX- Universal Precautions- CDC 42. 700.XXX- Universal Precautions Policy 800.XXX- Quality & Safety 1. 800.XXX- Quality and Performance Improvement Plan Form 2. 800.XXX- AED Machine Log 3. 800.XXX- Body Mechanics and Ergonomics 4. 800.XXX- Closure of Center (Unforeseen) 5. 800.XXX- Complaint and Grievance Resolution Policy 6. 800.XXX- Complaint and Grievance- Civil Rights 7. 800.XXX- Complaint- Completing Form and Process 8. 800.XXX- Complaint Form 9. 800.XXX- Complaint Letter- Requesting Emp. Response 10. 800.XXX- Complaint Letter to Complainant 11. 800.XXX- Complaints Tracking Spreadsheet 12. 800.XXX- Crash Cart- Set-Up 13. 800.XXX- Crash Cart- Inventory 14. 800.XXX- Crash Cart-Log (Seals) 15. 800.XXX- Crash Cart- Maintenance 16. 800.XXX- Drill- Behavior Disruption 17. 800.XXX- Drill- EMR Outage 18. 800.XXX- Drill- Internal Event 19. 800.XXX- Drill- Medical Emergency Form 20. 800.XXX- Drill- Missing Person 21. 800.XXX- Drill- Participant Roster 22. 800.XXX- Security Threat 23. 800.XXX- Drill- Severe Weather 24. 800.XXX- Drills- Annual Schedule 25. 800.XXX- Drills- Mock Code 26. 800.XXX- Emergency Preparedness Notification Call Tree 27. 800.XXX- Emergency Evacuation- Fire Explosion 28. 800.XXX- Emergency Evacuation- Sample Center Map 29. 800.XXX- Emergency Management

30. 800.XXX- Emergency Preparedness- Refrigerated Med Test Kits 31. 800.XXX- Emergency Response- Inventory Log 32. 800.XXX- Emergency Response- Inventory Tags 33. 800.XXX- Emergency Response Kit- Inventory 34. 800.XXX- Environment of Care- Annual Assessment 35. 800.XXX- Equipment- AED Daily Log 36. 800.XXX- Equipment- AED Monitoring 37. 800.XXX- Equipment- Annual Evaluation Form 38. 800.XXX- Equipment- Biomedical Inspections 39. 800.XXX- Equipment- Management 40. 800.XXX- Equipment- Management and Maintenance 41. 800.XXX- Equipment- Medical Device Reporting 42. 800.XXX- Equipment- Refrigerator and Freezer Temperature Log 43. 800.XXX-Equipment- Refrigerator Log- Cleaning 44. 800.XXX- Equipment- Refrigerator Log- Temperature with Ranges 45. 800.XXX- Equipment-Refrigerator- Monitoring and Maintenance 46. 800.XXX- Equipment- Refrigerator Temperature Monitoring 47. 800.XXX- Equipment- Refrigerator- Vaccine Storage 48. 800.XXX- Equipment- Safety Evaluation Form 49. 800.XXX- Equipment- Vaccine Refrigerator- Temperature Log 50. 800.XXX- External Events 51. 800.XXX- Fire Drill Record 52. 800.XXX- Fire Safety Inspection Checklist 53. 800.XXX- Fire Safety Version 2 54. 800.XXX- Fire Safety 55. 800.XXX- Fire Audit 56. 800.XXX- Hazardous Materials and Waste Inspection Checklist 57. 800.XXX- Hazardous Mat- Communication 58. 800.XXX- Hazardous Mat- Disposal 59. 800.XXX- Hazardous Mat- List Sample 60. 800.XXX- Hazardous Mat- List 61. 800.XXX- Hazardous Mat- Materials and Waste 62. 800.XXX- Hazardous Mat- Soiled Instrument and Item Transport 63. 800.XXX- Incident and Occurrence- Patient or Visitor Policy 64. 800.XXX- Incident and Occurrences-Corrective Action Documentation 65. 800.XXX- Incident or Occurrence Report- Building 66. 800.XXX- Incident or Occurrence Report- Employee Only 67. 800.XXX- Incident Report- Accident Form 68. 800.XXX- Incident Report- Patient or Visitor Form 2 69. 800.XXX- Incident Report Policy 70. 800.XXX- Incident Corrective Action 71. 800.XXX- Incident- Root Cause Analysis 72. 800.XXX- Incident- Sentinel Event 73. 800.XXX- Incident- Significant Investigative Report Form

74. 800.XXX- Incident- Significant Policy 75. 800.XXX- Medical Equipment Inspection Checklist 76. 800.XXX- Medical Equipment Safety Evaluation Form 77. 800.XXX- Near Miss Report 78. 800.XXX- Patient Satisfaction- Measuring Outcomes 79. 800.XXX- Patient Satisfaction- Phone Survey Spreadsheet 80. 800.XXX- Patient Satisfaction- Survey Policy 81. 800.XXX- Patient Throughput- Time Measuring 82. 800.XXX- Physical Environment- Non-Smoking 83. 800.XXX- PPE- OSHA Facts 84. 800.XXX- Quality and Performance Improvement Plan 2 85. 800.XXX- Quality and Performance Improvement Plan 86. 800.XXX- Quality and Performance Improvement- PDCA Form 87. 800.XXX- Quality Management- Sample Overarching Plan 88. 800.XXX- Safety and Health Overview 89. 800.XXX- Safety Inspection- Environment of Care- Annual Evaluation 90. 800.XXX- Safety- Accessing and Securing the Center 91. 800.XXX- Safety- Annual Assessment Form 92. 800.XXX-Safety- Annual Device Evaluations- OSHA 93. 800.XXX- Safety- Device Evaluation Form 94. 800.XXX- Safety- Electrical and Hazardous Energy 95. 800.XXX- Safety- Electrical Heater and Purifiers Prohibition 96. 800.XXX- Safety- Environmental Annual Assessment 97. 800.XXX- Safety- Environmental 98. 800.XXX- Safety- Facility Hazard Assessment 99. 800.XXX- Safety- Fire Control 2 100. 800.XXX- Safety- Fire Control 101. 800.XXX- Safety- Inspection Checklist 102. 800.XXX- Safety- Monthly Center Evaluation Form 103. 800.XXX- Safety- Monthly Center Evaluation Policy 104. 800.XXX- Safety- Panic Button and Security System 105. 800.XXX- Safety- Panic Button 106. 800.XXX- Safety- Pediatric 107. 800.XXX- Safety- Security Annual Review 108. 800.XXX- Safety- Security 109. 800.XXX- Safety- Weapons Prohibition 110. 800.XXX- Safety Survey- Annual 111. 800.XXX- Security Inspection Checklist 112. 800.XXX- Service Animals Access 113. 800.XXX- Sharps- OSHA Facts Sheet 114. 800.XXX- Utilities- Annual Review 2 115. 800.XXX- Utilities- Annual Review 116. 800.XXX- Utilities- Inspection Checklist 117. 800.XXX- Utilities- Outages

900.XXX- Medical Records 1. 900.XXX- Abbreviations- Do Not Use 2 2. 900.XXX- Abbreviations- Do Not Use List 3. 900.XXX- Abbreviations- Do Not Use 4. 900.XXX- Chart Audit Review- Tool 5. 900.XXX- Chart System 6. 900.XXX- Completion of Forms 7. 900.XXX- Documentation Guidelines 2 8. 900.XXX- Documentations Guidelines 9. 900.XXX- Medical Record Audit 10. 900.XXX- Medical Record Retention 11. 900.XXX- Missing Router 12. 900.XXX- Outages or Disruption 13. 900.XXX- Outages- Disruption in Patient Information Processes 14. 900.XXX- Patient Chart- Computer Down Policy 15. 900.XXX- Patient Chart- Discharge Instructions 16. 900.XXX- Patient Chart- Paper Nurses Note 17. 900.XXX- Patient Chart- Paper Progress Note 18. 900.XXX- Patient Chart- Paper 19. 900.XXX- Patient Medical Record- Processing 20. 900.XXX- Progress Notes 21. 900.XXX- Release of Medical Records Policy 22. 900.XXX- Release of Medical Records Form 23. 900.XXX- Release of Medical Records 24. 900.XXX- Release PHI- Patient Authority 25. 900.XXX- Release- Patient Authorization- PHI to Third Parties 26. 900.XXX- Request for Medical Records Letter Sample 27. 900.XXX- Retention and Management of Medical Records 28. 900.XXX- Router Form 29. 900.XXX- Router 30. 900.XXX- Superbill Sample