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Practice Management We know you can never find the time to create useful, nice-looking forms. Use ours. Download these forms and use and change them as you see fit. For Patients Advance Beneficiary Notice This form was created by the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) for your use. For more information, visit http://www.hcfa.gov/medlearn/refabn.htm. Advance Beneficiary Notice – Lab Work This is similar to the general notice above, but is specifically for laboratory work. Again, this form comes directly from the Center for Medicare and Medicaid Services. Access its Web site for more information. Assignment of Benefits Patient agrees to forward insurance or other third-party payment to practice should practice refuse assignment of benefits. Assignment of Benefits -- Spanish Closing Practice – Letter to Patients If you are closing your practice, you need to let patients know and advise them to find another physician. Here is a letter you can use to get the job done. Consent to Treat Authorization for a practice to treat a patient by the parent or legal guardian. HIPAA: Authorization for Use of Protected Health Information The Health Insurance Portability and Accountability Act requires authorization from patients for the release of protected health information for uses other than treatment, payment or health care operations. Here's a sample form for this purpose. Provided by Rachel Glitz, Paul Smith, and Becky Williams of Davis Wright Tremaine, LLP. HIPAA: Notice of Privacy Practices Straight from the HIPAA regulation, here is an outline to follow as you create your Notice of Privacy Practices. Medication Chart Instead of having patients carry all their medications to every visit, ask them to bring in this simple chart. It's a more efficient way to check for counterindications. You can even give patients a digital copy by saving it to a disk or e-mailing a copy. That makes it easy for patients to update it. Patient Information Form Collect basic information such as address, birth date, phone number, etc. Patient Information Form – Spanish Patient Satisfaction Survey An easy way to find out what patients think of your practice – and where you need to improve. Patient Satisfaction Survey – Spanish Records Release Form Patient agrees to allow practice to release health information as necessary to referring physicians and to provide pertinent information to payers. Records Release Form – Spanish
For Internal Use Business Associate Agreement: HIPAA The Health Insurance Portability and Accountability Act requires physicians to have their business associates -- claims processors or third-party billers, for example – agree to protect private patient data. Here's a sample form to use for this purpose. Forms provided by law firm Davis Wright Tremaine, LLP. Business Manager Evaluation Form Consider this template for annual or quarterly reviews of the performance of business managers in your practice. Of course, make sure your review reflects goals set at the beginning of the year or in a job description. Chart Preview Checklist Prepare well for visits so no one – including the patient -- has to wait. When you pull a chart for a pending visit, clip this preview form onto it. Pass it to the administrative and clinical areas to track what you need to capture during the visit – copayment, account balance, a copy of the insurance card – and prior to the visit – like lab test results ordered during the previous visit. Confidentiality Agreement Ask staff to sign this agreement, showing that they understand the need to protect patient confidentiality. Consultation Request Tell other physicians what you want and how you'd like to hear about what happened with your patient. New Practice Start-up Checklist Opening a new practice? Here are some of the things you will need to get done before the doors open. Physician Evaluation Form You give annual reviews to staff, why not to physicians? This form gives physicians feedback about their clinical quality, bedside manner, and ability to work with others. Referral Form Smooth patient referrals – and your relationship with specialists – with this easy form. Sign-in Form Placing a sign-in sheet on the reception desk makes the reception process less friendly. Instead, try asking patients to fill out this slip -- and do the necessary paperwork immediately. Staff Performance Review A sample review form for staff performance. Staff Workload Benchmarks General benchmarks on productivity for front and back office staff. Use these to evaluate the current performance of your staff and establish workload expectations. Surgery Scheduling Form Make sure you know everything you need to know. Telephone Message/Triage Form Get the message right the first time. Use this form to make sure all the information is covered. Test Tracking Workflow Sheet Make sure the tests you ordered get done, that you get the results and that the patients knows if anything is wrong. Print this form on carbon paper to create two copies: Send one copy to the lab. Keep the other in the office, but don't file it until the results come back and the patient is notified. If the form is still sitting out a month after the test was ordered, you'll know to follow-up. |