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CMS Addendum E Inpatient Only List

Cardiac Forms

• AICD and or Pacemaker Preop Eval Form (N-765)
• Request for Preoperative Cardiac Evaluation (N-372)

Surgery and Special Procedures

• Informed Consent Form N-712  English  |  Spanish
• Informed Consent Form N-712A  English & Spanish
• Blood Work Consent Form N-703-G 
• Cataract H&P N-483.6
• OR Case Request Form

Authorization to Release Medical Information Forms

• Authorization to Release Medical Information  English & Spanish  

Note: The form can faxed to 919-350-7985 or mailed to: Medical Record Services - ROI, 3000 New Bern Avenue, Raleigh NC 27610

Imaging Services

• Imaging Services Order Form

Rehabilitation

• Outpatient Rehab Registration Form
• WakeMed Rehab Outpatient Services Intake Profile - Spanish

Diabetes

• Pregnancy & Diabetes Program - Physician Order Form

Mail Order Forms

These forms are printed by WakeMed and can be ordered online and mailed to your practice in bulk at no charge.

Physician Office Orders

• Online order form