Forms

Following are some standardized forms you may find helpful.  These do not take the place of professional legal or billing advice.  Rather, they are a place to start when such advice is not readily available.  Other forms may be found under other resource sections.  For example, need a PQRI superbill?  Visit KLA's PQRI resource page.

Advance Beneficiary Notice (ABN) for Medicare

Are you using the current ABN form?  If you are not including an estimate of cost, you are not. 

Business Associates Agreement

A Business Associates Agreement is required between your practice and anyone who has access to patient's Protected Health Information.  This is a basic agreement that can be modified based on your state and the services rendered by the business associate.

Consent for Surgery

If you do surgical or other invasive procedures, you should always obtain a Consent For Surgery.  The best consents include a description of the procedures, possible risks, expected follow-up care and cost.  If you repeat the same surgery frequently, save your staff time by creating handouts that can be given to the patients.  Check with you speciality societies.  Many will have forms for this purpose.

Employee Forms

Every year a new federal W-4 should be completed for each employee.  Also include a completed copy of the I-9 with supporting documentation in the employee's file.  If you practice in a state with withholding tax, each employee should also complete a state withholding form such as the Mississippi Withholding Certificate.

If you use independent contractors to provide any type of service, ensure that a W-9 has been completed BEFORE the services are rendered.  It's not always easy to get this information after the service is complete.  The IRS requires independent contractor services to be reported at the end of the year.  No W-9 means a potential loss of deductibility for the services.

General Medical Records Release

This easy-to-modify Word general medical records release may be used if the patients or personal representative wishes you to receive records from others or vice versa.   Be certain to give the patient a copy and to keep a copy for your PHI file.

Home Health Care Tracking Form

Many primary care providers loose thousands of dollars in Medicare reimbursements each year because of failing to track the time involved in care plan oversight of home health care patients.  Our Home Health Care Tracking Form can help ensure that you capture reimbursement for the services you provide.  Keep these on hand to capture services provided to home bound patients each month.

Medicare Well Patient Visits

This Medicare Well Patient Visit Template can be used for the IPPE (Welcome to Medicare) and the Annual Wellness Visits.  The template presupposes that you maintain lists such as chronic problem and allergy lists.  Record keeping is minimized with cross references implicit in the template. The form is in Word so you can make modifications for your practice. The template also includes a worksheet for Personalized Prevention Plan Services. If you would like a word version of the template to modify, contact us.  Caring Connections referred to on the form offers free, downloadable, state-specific Advance Directives and other planning tools.  The CANS-MCI® or Computer-Administered Neurosychological Sreen for Mild Cognitive Impairment is a computer-based assessment that will be paid for with just a few uses.  For detailed information on this, contact Don Self at donself [at] donself [dot] com.

Medication List

This Medication List template includes medications prescribed by your office, other providers and over-the-counter drugs and supplements.

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