Forms Book Table of Contents
Forms # of Pages
Administrative
A-1 Administrative Filing System 4
A-2 Affidavit to Accompany Medical Records 1
A-3 Associate Physician/PA/FNP Evaluation 2
A-4 Associate Space-Sharing Checklist 1
A-5 How to Choose a Practice Management Consultant 1
A-6 Inventory Control System 1
A-7 Patient Count per Day Achievement 1
A-8 Patient Health History Update 1
A-9 Patient Registration 1
A-10 Patient Sign-in Sheet 1
A-11 Phone Nurse Log 1
A-12 Routing Slip 1
A-13 Signature Log 1
A-14 Weekly Computer Backup Log 1
Clinical
C-1 Brief History 1
C-2 Brief Visit Record 1
C-3 Cardiology Referral Request 1
C-4 Chart Setup 1
C-5 Consultation/Neurological 1
C-6 Diabetes Flow Sheet 1
C-7 Diabetes Health Maintenance Record 1
C-8 GI Consult or Flexible Sigmoidoscopy 1
C-9 GYN Exam/Procedure 1
C-10 Health History Sheet 3
C-11 Immunization History Record 1
C-12 Instructions for Outpatient Surgery 1
C-13 Instructions for Surgery with Overnight Stay 1
C-14 Lab Report 2
C-15 Mammography Referral 1
C-16 Medical Elective Surgery Procedures Agreement 1
C-17 Medical Problems Summary Sheet 1
C-18 Partial Problem List 1
C-19 Pelvic/PAP Evaluation 1
C-20 Prescription Sheet 1
C-21 Request for Records Release 1
C-22 Request for Surgical Procedure 1
C-23 Progress Note & Respiratory Illness Stamps 1
C-24 Surgery and Procedure Consent Form 1
C-25 Surgery Log 1
C-26 Surgery Scheduling Checklist 3
C-27 X-Ray and Imaging Appointment Request 1
Financial
F-1 Accounts Receivable Aging Report 1
F-2 Accounts Receivable Management Bonus Worksheet 1
F-3 Business Summary 1
F-4 Charges/Receipts-Annual Comparison 1
F-5 Checklist for Practice Billing System Audit 1
F-6 Collection Agency Account Tracking 1
F-7 Collection Letter 1 (Soft) 1
F-8 Collection Letter 1 (Hard) 1
F-9 Collection Letter 2 1
F-10 Collection Letter 3 1
F-11 Collection Letter 4 1
F-12 Credit Card Acceptance 1
F-13 E&M Coding Worksheet 1
F-14 Equipment Cost Analysis 1
F-15 Expense-Sharing Group Accounting Report 1
F-16 Fee Explanation 1
F-17 Financial Agreement/Schedule of Payments 1
F-18 Income and Expense Statement-Basic 1
F-19 Income and Expense Statement-Expanded 1
F-20 Internal and Miscellaneous Financial Controls 1
F-21 Internal Financial Control Checklist 1
F-22 OB Financial Agreement Explanation Sheet 1
F-23 Office Financial Policy 1
F-24 Patient Encounter Form 1
F-25 Petty Cash Reconcilliation 1
F-26 Petty Cash Voucher 1
F-27 Receipt 1
F-28 Statement 1
F-29 Treatment Estimate 1
F-30 Waiver of Payment Due to Economic Hardship 1
F-31 Worksheet for Division of Expenses in a Multidoctor Practice
3
Insurance
I-1 Chart Stickers for Avery Labels #5164 1
I-2 Checklist for Insurance Claim Processing 1
I-3 Electronic Claims Transmission Checklist 1
I-4 Insurance Company Summary Sheet 1
I-5 Insurance Predetermination Tracking 1
I-6 Insurance Rate Sheet 1
I-7 Insurance Tracer 1
I-8 Lifetime Beneficiary Claim Authorization 1
I-9 Lifetime Insurance Authorization 1
I-10 Medicare Benefits Explained 1
I-11 Medicare Limitation of Liability 1
I-12 Medicare Secondary Insurance Billing 1
I-13 Medicare Secondary Insurance Signature on File 1
I-14 Patient Registration Update 1
Managed Care
MC-1 Cap Rate Evaluation-Primary Care 1
MC-2 Capitation Split Formula 1
MC-3 Cost Analysis for Capitation Consideration 1
MC-4 Managed Care Capitation Fee-for-Service 1
Equivalency Report 1
MC-5 Managed Care Contract Review Checklist 1
MC-6 Managed Care Data Tracking Worksheet 1
Marketing
M-1 Marketing Analysis 1
M-2 Marketing Calendar 1
M-3 Marketing Goals 1
M-4 Market Survey Chart 1
Personnel
P-1 Advertising for New Staff 1
P-2 Affirmative Action Questionnaire 2
P-3 Employee Attendance Record 1
P-4 Employee Hiring Worksheet 1
P-5 Employee Information Record 2
P-6 Employee Review 2
P-7 Employment Agreement 1
P-8 Employment Application 2
P-9 Exit Checklist 1
P-10 How to Conduct a Reference Check 1
P-11 Independent Contractor Information 1
P-12 Payroll Record, Individual 1
P-13 Reviewing Resumes 1
P-14 Staff Survey 1
P-15 Telephone Screening Applicants 1
P-16 Time Card 1
P-17 Wage Statement 1
P-18 Year-End or Monthly Wage and Benefit Statement 1
Systems
S-1 Authorization for Disclosure of HIV Test Results 1
S-2 Authorization for Release of Records Pursuant to Subpoena 1
S-3 Family Physician Appointment Types for Scheduling 1
S-4 Goal Setting 1
S-5 Medical Recall Model 1
S-6 Medical Record Documentation Audit 1
S-7 Office Manager Checklist 1
S-8 Office Report Card 1
S-9 Patient Privacy Notice Regarding Subpoena 1
S-10 Patient Referral Log 1
S-11 Project Log 1
S-12 Recommended Termination Letter 1
S-13 Response to Invalid Deposition Subpoena for Medical Records
1
S-14 Staff Position Checklist 1
S-15 Task Analysis Checklist 2
S-16 Thank You for Referring 1
S-17 Wait Time Tracking 1
S-18 Weekly Schedule 1
S-19 Will Call List |
