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.

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.

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.

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.

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.

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.

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.