Main Content
SCDMH Enterprise Forms
Form Categories:
- Forms Management
- Administrative General Usage Avatar Inpatient System
- Outcomes Measures
- Community Mental Health Clinics and Centers
- Community Mental Health Clinics and Centers PRINT ONLY
- Corporate Compliance
- Information Technology CIO (Telephone)
- CQA Non-EMR Centers QA Section
- Duke Endowment
- Engineering Division Volunteer Emergency Fund Application
- Finance
- Human Resource Services (HRS)
- Workers’ Compensation
- Medical Records (see also C forms) Forms Management
- Medical Records PRINT ONLY
- Nursing Services
- Nursing Services PRINT ONLY
- Payroll/Personnel Property Physical Plant Service Public Safety
- Patient Rights
- Supply and Service Division State Personnel
- Volunteer Services
- Working Patient
|
Form |
Description |
|---|---|
 Forms Management |
|
| MS-4 | Forms Management Forms Specification |
| MS-5 | Forms Mgmt. Signature Authorization |
| MS-11 | Printing Requisition/Job Order Sheet |
| MS-18 | Request for Composition/R2web Format |
| MS-19 |
SCDMH F-26 Receipt Book Proof of Delivery Form |
| MS-21 | Form Justification Sheet |
| A | Administrative General Usage
Avatar Inpatient System |
| A-6 | Fax Coversheet |
| A-7 | Communications Slip |
| A-8 | SCDMH Security Report |
| A-8 DIS | SCDMH Security Report |
| A-10 | Memorandum |
| A-11 | DMH Memorandum |
| A-20 | Tuition Assistance Program Agreement |
| A-21 | Tuition Assistance Program Checklists |
| AS-13 | Permanent Improvement Project Request |
| AS-20 | Vehicle Accident Investigation Committee Disposition Request |
| AS-60 | Greenhouse Request for Plants |
| AS-62 | iaFolder User Authorization Form |
| AS-86 | Camera Index Worksheet |
| AS-86A | Index Worksheet Terminated Personnel Records |
| AS-92 | Records Shipment Request Authorization |
| AS-93 | Records Management Request for Storage |
| AVA-101 | AVATAR Problem Report |
| B | Outcomes
Measures |
| PS-200 | BPH Inpatient Survey Rev (PDF) |
| PS-201 | HPH Inpatient Survery Rev (PDF) |
| PS-300 | School Administrator Survey (PDF) |
| PS-301 | 2007 Youth Services Survey for Families (PDF) |
| PS-302 | 2007 Youth Services Survey (PDF) |
| PS-303 | QA Audit Tools for 2013 (PDF) |
| PS-304 | PSSAM Combined (PDF) |
| PS-305 | 3TMHSIP MST Youth (58394 -) (PDF) |
| PS-306 | 3D MST MHSIP Family Survey (PDF) |
| PS-307 | 3E MHSIP MST Youth (2148 -) (PDF) |
| PS-308 | 3E MST MHSIP Family Survey (PDF) |
| PS-309 | 3G MHSIP MST Youth (38368 ) (PDF) |
| PS-310 | 3G MST MHSIP Family Survey (PDF) |
| PS-311 | 3P MHSIP MST Youth (15724) (PDF) |
| PS-312 | 3P MST MHSIP Family Survey (PDF) |
| PS-313 | 3R MHSIP MST Youth (18200 ) (PDF) |
| PS-314 | 3R MST MHSIP Family Survey (PDF) |
| PS-315 | 3T MST MHSIP Family Survey (PDF) |
| PS-316 | 3D MHSIP MST Youth (5929 ) (PDF) |
| PS-317 | TriCounty Crisis Stabilization (PDF) |
| PS-318 | Georgetown MAC Survey (PDF) |
| PS-319 | Greenville Crisis Stabilization (PDF) |
| PS-320 | Marshall Street Crisis Stabilization (PDF) |
| PS-321 | Spartanburg MHC Dual Diagnosis (PDF) |
| PS-322 | Beckman Co-Occurring Survey (PDF) |
| PS-323 | Lancaster MHSIP MST Youth (PDF) |
| PS-324 | Lancaster MHSIP MST Family (PDF) |
| PS-393 | Orangeburg Adult MHSIP 2008 |
| PS-394 | Orangeburg YSSF 2008 |
| PS-395 | Orangeburg Annual YSS 2008 |
| PS-396 | Orangeburg ICS Parents |
| PS-397 | Orangeburg FSS Post Discharge |
| PS-398 | Orangeburg CSS |
| PS-399 | Orangeburg CASS |
| PS-400 | Orangeburg Annual SS |
| PS-401 | Orangeburg FSS Annual |
| PS-402 | Orangeburg ICS Adults |
| PS-403 | Orangeburg Svy |
| PS-404 | Orangeburg C&A Consumer Survey |
| PS-500 | TCM Medical Records Review Tool (Adobe Reader) |
| C | Community
Mental Health Clinics and Centers
|
| C-20 | CMHC Screening |
| C-39 | Generic Service Ticket |
| C-39 | Generic Service Ticket (PDF) |
| C-52 | Discharge Summary or Transition Plan |
| C-67 | Medication Monitoring Form |
| C-67A | Child and Adolescent Medication Monitoring Form |
| C-69 | Special Client Consumer Notification & Consent |
| C-107 | Consent To Examinations and Treatment(MS Word) |
| C-108 | Crisis Stabilization Form |
| C-166 | W R A P CSN form |
| C-166 | W R A P CSN form (PDF) |
| C-168B | Physician’s Medication Orders and Service Notes |
| C-168C | Physician’s Medication Orders and Service Notes |
| C-168D-CA | Community Crisis Communication or Physician's Medication Orders |
| C-174 | Adverse Incident Report |
| C-175 | Clinical Service Ticket Multi-Client Services |
| C-176 | MIMS Note |
| C-176 | MIMS Note (PDF) |
| C-181 | Plan of Care |
| C-182 | ITP Progress Summary |
| C-182 | ITP Progress Summary X2 |
| C-182 Greenville | ITP Progress Summary - Greenville |
| C-183 | Initial Clinical Assessment |
| C-184 | CAF Initial Clinical Assessment |
| C-188L | PRS Weekly Note w Lines |
| C-188 | PRS Weekly Note w/o Lines |
| C-190L | Daily Clinical Service Note W/Lines |
| C-190 | Daily Clinical Service Note W/O Lines |
| C-192 | Mental Status Exam |
| C-193 | Clinical Assessment Update |
| C-200 | Client Orientation Checklist |
| C-203 | Personal Safety Plan |
| C-204 | Targeted Case Management Needs Assessment |
| C-205 | Initial Crisis Evaluation/Brief Assessment |
| C-206 | Confidential Mental Health Filtering Questions SBIRT Referral |
| C-207 | Authorization To Disclose SCDMH Protected Health Information-SBIRT Referral Only |
| C-211 | Abbreviated Audit Tool for Transfers & Discharges Only |
| C-216 | RPS Daily Clinical Service Note |
| C-220 | CMHC Clinical Referral to Care Coordination |
| Charleston-18 | MMO Referral Form (MS Word) |
| CMS-R-131 | Advance Beneficiary Notice of Noncoverage (ABN) |
| GRV-29 | Adult Client GMHC Triage |
| GRV-35 | Greenville MHC Client Insurance Info |
| ORG-19 | Adverse Drug Reaction Report |
| ORG-22 | Treatment Attendance Agreement |
| ORG-22A | Treatment Attendance Agreement (Altered Margins) |
| C/PO | Community Mental Health Clinics and Centers PRINT ONLY |
| Cola Area-91 | Friendship Center Drop-In Referral Form |
| Cola Area-92 | Friendship Center Treatment Referral Forms |
| Cola Area-93 | Detention Order Request |
| C | Corporate Compliance |
| CC-1 | Corporate Compliance Reporting Form |
| CC-2 | Corporate Compliance Response Form (MS Word) |
| CC-3 | Reporting / Response Continues (MS Word) |
| D | Information
Technology CIO (Telephone) |
| CSR | CIO Communication Service Request |
| CSRB | CIO CSR Attachment |
| DIS-22 | DIS Telephone Service Request Form |
| DP-6A | IT Request for services |
| DP-6B | IT R2Web Publishing Request |
| DP-6B | IT R2Web Publishing Request |
| DP-6C | Web Development Request |
| DP-7 | SCEIS |
| DP-64 | Internet Acceptable Use Policy |
| DP-65 | IT Security Update Request |
| DP-65S | IT SAP Security Update Request |
| DP-159 | IT Flexible Schedule Request |
| NWS-1 | User Authorization Form |
| NWS-2 | Notebook Computer Use Policy |
| R-25 | Daily Long Distance Telephone Calls |
| VMCSR | CIO Voice Mail CSR |
| VMCSRA | CIO Voice Mail CSR Attachment |
| DE | Duke Endowment |
| Duke-01 | Initial ED Consult |
| Duke-02 | Follow-Up ED Consult |
| Duke-03 | Violence Risk Appraisal |
| Duke-04 | Suicide Risk Appraisal |
| Duke-05 | Telepsychiatry Consult Request Form |
| E | Engineering Division Volunteer Emergency Fund Application |
| E-21AA | Vehicle Mgmt. Request for Transportation |
| E-22 | Request For Out of State Travel |
| E-26 | Monthly Trip Log |
| E-26A | Monthly Trip Log Continuation |
| V-16E | Dr. Irwin E.Phillips' Fund |
| F | Finance |
| F-9 | General Deposit Form (.xls) |
| F-10 | Composite Bank Account Deposit |
| F-11 | Invoice |
| F-11A | Invoice Voucher |
| F-12 | Employee Travel Document |
| F-12C | Employee Travel Document Supplement |
| F-12C | Employee Travel Document Supplement (PDF) |
| F-19 | Journal Entry Request |
| F-22 | Request for Patient Fund Withdrawal |
| F-100 | SCDMH Procurement Card Application |
| F-102 | Confidentiality Information Form |
| F-104 | SCDMH Application for Procurement Card Liaison |
| F-105 | SCDMH Application for Works Access |
| F-157 | SCDMH Rate Increase |
| F-159 | Flexed Work Schedule |
| F-160 | Employee Time Sheet |
| F-162 | Request for Overtime Comp Time |
| F-163 | Statement of Services Rendered |
| F-194 | Adjustment to Time-Attendance |
| F-191 | Authorization Agreement for Electronic Deposits |
| F-196 | Financial Support to Promote Community Housing |
| F-198 | AVATAR-PM Refund Request Form |
| F-199 | CFMS Transfer To/From AVATAR Billing |
| F-200 | Employee Recognition Pre-Qualification Checklist (XLS) |
| F-201 | Waiver and/or Write-Off Compromise of Medical Care Charges |
| FAT | Fiscal Analysis Tracking Form |
| H | Human
Resource Services (HRS) |
| DIPS-14 | Conflict of Interest Form |
| HRS-3 | Paycheck Information |
| HRS-3A | Employment Reference Check |
| HRS-3B | Dual Employment Request |
| HRS-4 | Applicant Interview Form |
| HRS-7 | Applicant Listing and MTE Determination |
| HRS-10 | Temporary Employment Statement of Understanding |
| HRS-13 | Property and Fiscal Responsibilities |
| HRS-17 | Employee Harassment Form with Policy |
| HRS-18 | Performance Commendation |
| HRS-20 | Nov 2007 Request for Salary Approval |
| HRS-20A | New Employee Salary Documentation |
| HRS-22 | Bonus Award Form |
| HRS-23 | Light Duty Request/Approval Form |
| HRS-24 | Affidavit of Common Law Marriage |
| HRS-27 | EPMS Rating (PDF) |
| HRS-27 | EPMS Rating |
| HRS-27 | EPMS Rating expanded format |
| HRS-33 | Personnel Action Form |
| HRS-35 | Employee Clearance Procedure |
| HRS-40 | Certificate of Service |
| HRS-66 | Employee Substandard Performance Warning |
| HRS-93 | Request for Consideration |
| HRS-102 | Exit Interview |
| HRS-115 | Grievance Review Request |
| HRS-140 | Position Description (PDF) |
| HRS-140 | Position Description |
| HRS-146 | Time Away From Duty |
| HRS-153 | Written Warning |
| HRS-154 | Notice of Suspension |
| HRS-155 | Record of Employee Counseling |
| HRS-159 | Request to Fill Position |
| HRS-160 | Emergency Contact |
| HRS-161 | Outstanding Employee Nomination |
| HRS-163 | Record of Conversation Regarding Report of Off-Duty Misconduct |
| HRS-166 | Leave Donation Request |
| HRS-167 | Recipient Leave Request |
| HRS-168 | Furlough Request Form |
| HRS-169 | Organizational Management Change Form |
| HRS-171 | SCDMH Notice & Consent Pre-Employment Drug Testing |
| HRS | Workers’ Compensation |
| HRS-16 | Report of Injury |
| HRS-147 | Workers' Compensation Election Form |
| HRS-148 | SCDMH Employee/Supervisor Notification |
| M | Medical
Records (see also C forms)
Forms Management |
| CBHS3 | Code Blue Critique |
| CBHS3A | Code Blue Medical Emergency Practice Drill |
| CMT-21 | Resident Count Sheet |
| CMTNCC-129 | Hydration Risk Appraisal Checklist |
| DIPS-17 | Model Reply to Request To Inspect and/or Copy SCDMH Protected Health Information |
| DIS-03 | Code Blue Critique |
| DIS-03A | Code Blue / Medical Emergency Practice Drill |
| DIS-04 | Restraint/Seclusion Debriefing Form |
| DIS-20 | Flu Checklist |
| DIS-26 | Health Insurance Questionnaire/Work Sheet |
| DIS-30 AT | AT Master Signature List |
| DIS-30 EDU | EDU Master Signature List |
| DIS-30 LPP | LPP Master Signature List |
| DIS-30 OTHER | OTHER Master Signature List |
| DIS-30 PSYCHOLOGY | PSYCHOLOG Master Signature List |
| DIS-30 SW | SW Master Signature List |
| Forensic-01 | Forensic Division Psychiatric Social Work Admission Assessment |
| Forensic-02 | Forensic Division Social Work Re-Admission Assessment |
| Forensic-03 | Forensic Division Treatment Planning Notes |
| Forensic-04 | Activity Therapy Assessment |
| Forensic-05 | Forensic Division Activity Therapy Re-Assessment |
| Forensic 07 | Master Treatment Plan |
| Forensic 08 | DIS Forensic Division Master Treatment Plan |
| Forensic 09 | Annual Social Work Assessment Summary |
| Forensic 12 | Monthly Progress Report |
| Forensic 13 | Annual History & Physical Examination |
| Forensic 22 | Request for Patient Fund Withdrawal |
| Foresnsic 23 | Episodic Care Plan |
| M-005 | Community Hospital EMTALA Transfer |
| M-015 | Application for Child in Need of Emergency Admission |
| M-017 | Part II Certificate of Licensed Physician Examination of Child in Need of Emergency Admission |
| M-102 | Consent Or Denial Of Consent To Use Clozaril Medication |
| M-103 | Consent for Audio/Video Taping during Training Sessions |
| M-105 | Patient Disposition |
| M-110 | Neuroleptic (Antipsychotic) Consent Form |
| M-110 CMTNCC | Neuroleptic Medication Consent Form |
| M-111 | IFS Addendum Notice |
| M-120A | PBH Affidavit of Personal Service |
| M-122A | Petition for Judicial Admission |
| M-130 | Application for Involuntary Emergency Hospitalization For Mental Illness |
| M-131 | Certificate of Licensed Physician Exam for Emergency Adm, Part II |
| M-134 | (Part One) Application for Involuntary Emergency Admission for Chemical Dependency |
| M-144 | Application for Discharge |
| M-190 | Patient's Right to Petition for Re-Examination |
| M-192 | Certification of Medical Infirmity |
| M-193 | Information Sheet for Restoration Patients |
| M-194 | Information Sheet for Defendants Who Are Admitted to the Hospital for Competency Evaluation |
| M-195 | Information Sheet for Defendants Who Are Admitted to the Hospital for Criminal Responsibility Evaluation |
| M-202 | Physician Progress Note |
| M-203B | Treatment Needs Assessment |
| M-203G | Master Treatment Plan |
| M-204A | Treatment Plan Review/Update |
| M-207B | Organ Tissue Donation Physician Progress Note |
| M-208 | Seclusion / Restraint Letter |
| M-208 E/CHP | Admission Orders Page 1 |
| M-208 E/CHP | Admission Orders Page 2 |
| M-208EEEE CHP/DoIS | Seclusion/Restraint Order Form and Face-To-Face Evaluation |
| M-208EEEEE | Practitioner Orders For Pass/Discharge |
| M-209 CMT | Physician's Restraint Orders and Progress Note-Professional Services |
| M-212 | CMT History and Physical |
| M-214 | Acute Care Certification/Recertification |
| M-216 | Certificate of Inability to Consent ID of Substitue Decision-Maker |
| M-217A | Certification Recertification |
| M-220 CMT | Physical Restraint Consent - Professional Services |
| M-224 | AIMS Abnormal Involuntary Movement Scale |
| M-225-DIS | Practitioner Orders |
| M-226 DIS | DIS Patient Immunizations Assessment and Physician Order (MS Work) |
| M-227 | Practitioner Orders Sliding Scale Insulin |
| M-228 | CBHS Physician Query Form |
| M-230 | DIS Pneumococcal Pneumonia Immunization Ass & Order Form Jan 09 |
| M-231 | H1N1 Influenza Immunization Assessment & Order Form |
| M-232 | Election of Code Status |
| M-233 | Practitioner Orders Clozaril/Clozapine Protocol |
| M-303 | Patient Visitor's List |
| M-340 | Application for Voluntary Admission Morris Village Alcohol & Drug Addiction Treatment Center |
| M-340A | Application for Voluntary Admission WSHPI |
| M-343 | Wellbeing and Security Preference |
| M-344 | Morris Village Clinical Weekly Progress Note |
| M-350C | Mini-Mental Status Exam Bilingual |
| M-357 | Pet Therapy Consent Form |
| M-400 | Multidisciplinary Therapeutic Documentation Record |
| M-402C | Admissions Initial Data Sheet |
| M-402D | Patient Orientation To Unit |
| M-406 | Correspondent and/or Financial Representative Change |
| M-407 | Interdisciplinary Progress Notes |
| M-408 | Conversation Record |
| M-411A | Glucose Monitoring |
| M-412/CHP | Admission Medication Reconciliation and Order Form |
| M-419 | DIS Special Treatment Procedure Log |
| M-420 | Registered Nurse Seclusion/Restraint Assessment |
| M-421 | CBHS Agitation Assessment |
| M-426 | CBHS Hospital Transfer Record |
| M-427 | DIS Inpatient Suicide Risk Assessment |
| M-429 | PRN Agitation Order Set |
| M-450C | Record of Transmittal |
| M-450D | Authorization To Disclose PHI |
| M-450I | Authorization To Release Information, Request For Payment & Assignment of Benefits |
| M-450J | Authorization to Share Information with Family & Others |
| M-451 | Request to Inspect Protected Health Information |
| M-452 | Request to Amend Protected Health Information |
| M-453 | Accounting Log of PHI Disclosures |
| M-455 | Patient Medical Equipment/Device Release |
| M-498 | Patient Personal Medication Inventory Form |
| MV-93 | Patient Orientation |
| MV-104 | Voluntary Patient, Request for Discharge |
| MV-106 | Multifamily Group Therapy Progress Notes |
| MV-136 | MV Alcohol & Drug Treatment Center 30-Day Follow-Up Survey |
| MV-137 | Receipt for Delivery of Items |
| MV-138 | Behavioral Contract |
| MV-139 | Clinical Staff's Initial Contact W/Patient |
| PS-132 | CBHS Community Outing |
| R-3 | Notification of Rights, Privacy & Advance Directive Query |
| R-7B | Judicial Re-Examination Letter |
| R-7C | Voluntary Admission Letter |
| R-9 | Confidentiality Agreement/Record of Visitation |
| R-24 | Information Sheet |
| R-26 A DIS | Probate Judge Notice DIS |
| R-27 | Service of Legal Papers |
| R-40 | Letter Regarding Information |
| R-69 | Instructions for Employees Escorting Patients |
| R-83 | Podiatry Clinic |
| SVPTP-2 | Request to SVPTP Staff |
| SVPTP-3 | Resident Grievance Form |
| SVPTP-4 | Grievance Appeal Form |
| SVPTP-5 | Book Request Form |
| SVPTP-7 | Master Treatment Plan |
| SVPTP-8 | Quarterly Progress Plan |
| SVPTP-10 | SVPTP Diagnostic Face Sheet (MS Word) |
| WS@CHP-1 | Activity Therapy Department Progress Note Sheet |
| WS@CHP-2 | Activity Therapy Constructive Leisure Monthly Attendance (MS Word) |
| WS@CHP-3 | Activity Therapy Assessment |
| WS@CHP-4 | Activity Therapy Annual Assessment |
| WS@CHP-5 | Wellness and Rehabilitation Assessment |
| WSHPI-137 | CBHS Consent For Minors To Participate in Activities Outside SCDMH (English) |
| WSHPI-144 | WSHPI De-Escalation Preference Form |
| WSHPI-151 | WSHPI-151 Youth Rational Decision Evaluation |
| MR | Medical
Records PRINT ONLY |
| Cola Area-87 | Medication Management Worksheet |
| Cola Area-88 | Physician's Medication Orders and Service Notes |
| DIS WSHPI-130 | Psychiatric Social Work Admission Assessment |
| Forensic-11 | Psychiatric Social Work Admission Assessment (Child) |
| M-001 | Identification and Summary Sheet |
| M-208 EEEEE | CHP Practitioner Orders for Pass/Discharge PRINT ONLY |
| M-208E MV | MV Admission Orders PRINT ONLY |
| M-295K | DIS Specialty Clinics EKG-EEG |
| M-510 | Annual History & Physical WSHPI |
| M-511 | History & Physical MultiDisciplinary Assessment PRINT ONLY |
| M-530 | Nursing Discharge Summary & Instructions |
| M-545 | WSHPI Social Work Assessment Addendum PRINT ONLY |
| NS-21 | Seizure Observation & Nursing Care Record |
| N | Nursing
Services |
| DIS-24 | Refrigerator Log |
| M-420 | Registered Nurse Seclusion / Restraint Assessment |
| NS-1 | Licensed Nurse Master Signature List |
| NS-5 | CBHS Code Blue/Medical Emergency Flow Sheet |
| NS-10 | Early Recognition Intervention Criteria (ERIC) |
| NS-27 | Daily Living Flow Sheet |
| NS-36 | CBHS Fall Reduction Interventions |
| NS-37 | Clinical Opiate Withdrawal Scale (COWS) |
| N | Nursing
Services (Print Only) |
| NS-79_pg1 | Patient Count Record, Pg. 1; 07:30 AM - 03:15 PM |
| NS-79_pg2 | Patient Count Record, Pg. 2; 03:30 PM - 11:30 PM |
| NS-79_pg3 | Patient Count Record, Pg. 3; 11:45 PM - 07:15 AM |
| P | Payroll/Personnel Property Physical Plant Service Public Safety |
| P-13 | Property/Fiscal Responsibilities |
| Public Safety-13 | Safety/Security Trip Assessment Sheet |
| P-14 | Application for leave |
| P-14A | Travel Authorization Form |
| SD-14 | SCDMH Statement Of |
| PDR | Patient Data Report |
| PDR-1 | Intake Form for CIS |
| PDR-2 | CMHS Client Discharge |
| PDR-10 | Monthly Report of NON-DMH Hospitalizations |
| PR | Patient Rights |
| PR-3 | Request for Review |
| PR-11 | Privacy Practices Complaint |
| PR-13 | Request for Review of Designated Record Set |
| S | Supply and
Service Division State Personnel |
| S-3 | Non-Expendable Property |
| S-5 | Supplies Issue/Turn-In Request |
| S-5C | Request For Issue or Turn-In Of Supplies |
| S-5CC | Request For Issue or Turn-in of Advances |
| S-5E | Surplus Salvage Turn-In Request |
| S-7 | Request Issue/Turn-in of Equipment Over $1,000 |
| S-8 | Property Transfer |
| S-18 | Turn-in Document (TID) |
| SCF-101 | State Job Application |
| V | Volunteer
Services |
| V-5 | One Time Activity Form |
| V-7 | Record of and Receipt for Contributions |
| V-7A | Record Of and Receipt For Contributions (List) |
| V-9 | Proposed Fund Raising Activity |
| V-10 | Volunteer Orientation With Resident/Consumer Contact |
| V-11 | Volunteer Services Orientation W/Minimal or no Resident Contact |
| V-12A | Volunteer Report |
| V-16E | Dr. Irwin E.Phillips' Fund |
| V-17 | Volunteer Occasional Service Application |
| V-18 | Directive Statements |
| V-19 | The Art of Recovery Consent |
| W | Working
Patient |
| WPP-101 | Patient Payroll: Cancel or Supplemental Information |