Med-RecSystems.com
  • Home
  • Training
    • All Events
    • Health Information Coordinator
    • ICD-10-CM/PDPM
    • Residential Records
    • HIPAA and Release of Information
    • Critical Areas
  • Services
    • Long Term Care
    • Ambulatory Surgery Centers
    • Physician Offices
    • Dialysis Centers
  • About Us
  • Forms & Manuals
    • Policy & Procedure Manuals >
      • Long Term Care – Indiana
      • Long Term Care - National
      • Residential - Indiana
    • Long Term Care Forms
    • Ambulatory Surgery Centers Forms
  • Contact Us

Ambulatory Surgery Center Forms

Any 2-sided form may be printed HTT or HTH.  Rates subject to change.
HTT= Head to Toe: Used for top bound charts
HTH= Head to Head: Used for side bound charts

#0808
Authorization for Release of Information
This form is used to obtain the authorization from the patient to release their clinical records to a requesting party. 
Sold in pads of 100.
Choose the quantity
Department (*Required Field)

#0848
Transfer/Referral Form
This form is to be completed when the patient is referred to the hospital or other facility. 
Sold in pads of 100.
Choose the quantity
Department (*Required Field)

#0861
Medication Reconciliation form
This form is used to document the patient’s allergies and current medications with a section to document whether to continue, hold or discontinue the medications upon discharge.
Choose the quantity
Department (*Required Field)

#0892
Verbal Orders
This form is used to document verbal orders from providers.
Choose the quantity
Department (*Required Field)
​In Business Since 1984
MED-REC SYSTEMS, P.O. Box 40471, Indianapolis, IN 46240  |  (317) 852-9733
Copyright 2021 Med-RecSystems |  mainoffice@med-recsystems.com
Med-Rec Systems provides health information consultation in long term care facilities, ambulatory surgery centers, physician practices and dialysis centers.  Services include, but are not limited to ICD-10-CM training, clinical record forms, workshops, medical coding, and MDS validation.