Forms and Resources


ANAI   ANMC   Clinical   Creekside   DBS   Gamma Knife   Medicaid   Neuro Intervention   Patient   Providence   Regional   Shunt   


ANAI - Go to top

New patient referral formpdf 203KB

ANMC - Go to top

Radiology image request formpdf 487KB

Clinical - Go to top

Alaska Comfort One - Patient Handoutpdf 3.0MB
CDC growth charts link
Cleveland Clinic - Image Uploadpdf 4.1MB
Dermatome chartjpg 115KB
Disability parking permit (handicap placard)pdf 154KB
ETV success scorepng 95KB
Inpatient consult sheetpdf 26KB
Mayo Clinic ImageSharepdf 210KB
Medtronic MRI safety neuromodulation (7/2019)pdf 173KB
MRI safety - Sugita aneurysm clipspdf 316KB
MRI safety - Yasargil aneurysm clipspdf 82KB
Myotome chartjpg 57KB
Myotomes - legjpg 105KB
Outpatient consult sheetpdf 29KB
STEALTH imaging protocol - 1pdf 154KB
STEALTH imaging protocol - 2pdf 1.5MB
STEALTH imaging protocol - 3pdf 246KB

Creekside - Go to top

COVID attestationdocx 12KB
Creekside consentpdf 742KB

DBS - Go to top

Medtronic DBS battery IPG depletion chartpdf 60KB
Medtronic DBS Electromagnetic Interference (EMI)pdf 2.9MB
University of Florida - IPG life estimator link

Gamma Knife - Go to top

Leksell Gamma Knife Icon Console 11.4 Instructions for Usepdf 18.9MB
Leksell GammaPlan 11.3 Online Reference Manualpdf 29.7MB

Medicaid - Go to top

Certification of Medical Necessity for Travel (11/17/2022)pdf 348KB
Plan of Care (7/12/2022)pdf 540KB
Remittance Advice (RA) Message (12/5/2022)pdf 24KB
Request for Escort Form (3/18/2020)pdf 413KB
Required Documentation for Travel (12/5/2022)pdf 337KB

Neuro Intervention - Go to top

Regional - neurovascular consentpdf 26KB
Regional - radiology orderspdf 197KB

Patient - Go to top

ANAI Demographics Form 2014doc 53KB
ANAI HIPAA Notice of Privacy Policydoc 48KB
ANAI History Sheetdoc 38KB
ANAI Medication-Check in List doc 28KB
Financial Policy 2014doc 26KB
Medical Request formdoc 32KB
Notice Acknowledgement of Receipt Notice of Privacydoc 23KB
Provider Medical Request Release Formpdf 50KB

Providence - Go to top

Alaska imaging locations - method to transfer to Synapsepdf 29KB
Alaska imaging locations - method to transfer to Synapsexlsx 13KB
Cancer conference form - brain tumor (2020)docx 55KB
Cancer conference form - city wide (2020)docx 55KB
Cancer conference form - pediatric (2020)docx 55KB
COVID attestationpdf 77KB
H&P - Short Formpdf 679KB
Pre-op medication instructions (updated 2/2019)pdf 201KB
Providence consentpdf 452KB
Radiology exam with anesthesia orderspdf 465KB
TCD formpdf 52KB
Wound carepdf 875KB

Regional - Go to top

1) Surgery - preoperative orderspdf 323KB
2) Surgery - consentpdf 456KB
3) Surgery - schedulingpdf 551KB
4) Surgery - checklistpdf 156KB
5) Surgery - driver acknowledgmentpdf 211KB
COVID attestationpdf 90KB
COVID surgery guidelinespdf 880KB
H&P - Short Formpdf 25KB
Medicare Order Form (MOF)pdf 88KB
Neuro radiology pre-procedure orderspdf 795KB
Operating room observer consent formpdf 32KB
Ostomy carepdf 559KB
Pre-operative stop surgical site infection (SSI) orderspdf 701KB
Regional telephone directory (7/23/2015)doc 188KB
Surgical antibiotic prophylaxis (5/2019)pdf 1.2MB
Wound carepdf 511KB

Shunt - Go to top

Codman hydrocephalus catalog 1pdf 2.0MB
Codman hydrocephalus catalog 2pdf 6.1MB
Flow control performance settingsjpg 30KB
Medtronic delta performance settingsjpg 20KB
Shunt valve x-ray identification #1 (ISPN guide) link
Shunt valve x-ray identification #2 link
Uni-shuntjpg 124KB
Valve - Certasjpg 23KB
Valve - Certas (performance settings)jpg 75KB
Valve - Delta performance settingsjpg 53KB
Valve - Hakim Medosjpg 195KB
Valve - Hakim Medos valve adjustment guidepdf 1.4MB
Valve - proGavjpg 51KB
Valve - PS Medicaljpg 95KB
Valve - Strata IIjpg 269KB
Valve - Strata MRjpg 40KB
Valve - Strata NSCjpg 47KB
Valve - Strata performance settings (all)pdf 2.5MB