Standard Office Forms
Physician's Office Financial Policy
It is important that your office disclose its policies regarding insurance reimbursement,
missed appointments, record photocopying fees and the like. With some minor customization,
you may want to use a policy such as this Financial Policy.
Publication Date: 07/2008
Copyright 2008.
Letter Terminating Physician-Patient Relationship
Many healthcare providers must occasionally terminate patient relationships due
to professional, legal or personal reasons. Improperly terminating a patient relationship
can have serious professional and legal repercussions. This letter provides a good
starting point for drafting a termination letter that will be appropriate for your
particular situation.
Publication Date: 05/2008
Copyright 2008.
HIPAA Authorization
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), an
individual or entity requesting copies of medical records must provide an authorization
executed by either the patient or the patient’s representative. The form of
authorization provided herein complies with the requirements of HIPAA and may be
used by your office for this purpose.
Publication Date: 02/2008
Copyright 2008.
Prompt Payment Letter
This letter may be sent after the payment deadline has expired under the relevant
state prompt payment statute. The prompt payment details (e.g., dollar amount of
claim, time period, etc.) are provided elsewhere on this Legal Corner and should
be reviewed carefully prior to sending this letter.
Publication Date: 03/2008
Copyright 2008.
In-house Patient Pre-Collection Letter
This letter is intended to be used by a healthcare provider’s office after
a patient has already received multiple patient statements, yet before such patient
has been referred to an outside collection agency. This letter must be sent on a
provider’s letterhead; if a provider disguises his identity and implies that
he is an outside collection agency, he/she may become subject to penalties under
the Federal Fair Debt Collection Practices Act.
Publication Date: 03/2008
Copyright 2008.
In-house Patient Pre-Collection Letter - II
This letter is intended to be used by a healthcare provider’s office and may
be sent to an out-of-network patient who has received direct reimbursement from
his or her insurance company, but has not paid the provider’s office. Such
a situation may arise if the provider has either refused to accept assignment of
the claim; attempted to accept assignment, but also collected partial payment from
a patient; or simply due to an insurance company processing error. This letter must
be sent on a provider’s letterhead; if the sending provider disguises his
identity and implies that he is an outside collection agency, he/she may become
subject to penalties under the Federal Fair Debt Collection Practices Act.
Publication Date: 03/2008
Copyright 2008.
Litigation/Worker’s Compensation Status Inquiry.
This letter may be sent to an attorney representing a patient in a worker’s
compensation or personal injury matter in order to determine status of the case
and remind the attorney that the claims are pending. Such patients should never
be referred to collection while their cases are pending.
Publication Date: 03/2008
Copyright 2008.