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The premier provider of medical professional liability insurance for physicians, other medical professionals, clinics, and hospitals in Washington, Oregon, and Idaho. |
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Chapter 1: Communication and Rapport
Chapter 2: Medical Records—Documentation and Release Chapter 3: Medical-Legal Issues Chapter 4: Patient Care Issues Chapter 5: Practice Management Issues Chapter 6: Treatment of Minors Chapter 7: Sample Forms and Letters |
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Risk Management Reference Guide - Chapter 7
Sample Forms & Letters
The practice of medicine is full of documentation challenges. To help, Physicians Insurance has compiled a library of sample forms and letters for use by members. These documents are designed to be used by health care providers as examples that can be downloaded and tailored to meet the unique needs of each practice or patient-care setting. HIPAA Informed Consent & Refusal Medical Records Treatment of Minors Challenging Patients Closing Your Practice Medication/Pain Management Depositions & Witnesses Quality Improvement (CQIP) Patient SAFE Employee-Related Issues Miscellaneous HIPAA Accounting Log for Protected Health Information Disclosures (Word 48 KB) (PDF 100 KB) Authorization to Use or Disclose Protected Health Information (Word 77 KB) (PDF 41 KB) Denying Request to Access Protected Health Information (Word 66 KB) (PDF 21 KB) Denying Request to Correct or Amend Protected Health Information (Word 68 KB) (PDF 19 KB) HIPAA Privacy Forms in German, Russian, Spanish, Tagalog, and Vietnamese Notice of Privacy Practices (Word 83 KB) (PDF 39 KB) Notice of Privacy Practices Acknowledgment (Word 68 KB) (PDF 12 KB) Request to Correct or Amend Protected Health Information (Word 30 KB) (PDF 23 KB) Response to Defective Subpoena or Incomplete Request to Disclose Protected Health Information (Word 37 KB) (PDF 18 KB) Revocation of Authorization to Use or Disclose Protected Health Information (Word 69 KB) (PDF 17 KB) Back to Top Informed Consent & Refusal Informed Consent—Patient Education Version (Word 33 KB) (PDF 34 KB) Informed Consent—Standard Version (Word 31 KB) (PDF 67 KB) Informed Refusal of Care Form (Word 23 KB) (PDF 11 KB) Informed Refusal of Care Letter (Word 28 KB) (PDF 13 KB) Back to Top Medical Records Diagnostic Test Tracking Log (Word 44 KB) (PDF 100 KB) Diagnostic Testing and Consult Tracking Log (Word 39 KB) (PDF 42 KB) Medical Records Self-Assessment Guide (Word 37 KB) (PDF 83 KB) Signature Log (Word 12 KB) (PDF 76 KB) Telephone Triage Form (Word 27 KB) (PDF 39 KB) Back to Top Treatment of Minors Advance Consent to Treat Minors (Word 16 KB) (PDF 76 KB) Kinship Caregivers Informed Consent Declaration for Minors (Word 16 KB) (PDF 96 KB) Back to Top Challenging Patients Complaint/Grievance Resolution Letter (Word 8 KB) (PDF 76 KB) Patient Care Agreement Form (Word 16 KB) (PDF 76 KB) Termination of Care Letter (Word 23 KB) (PDF 12 KB) Upset Patient Letter (Word 12 KB) (PDF 76 KB) Back to Top Closing Your Practice Closing Your Practice Letter (Word 12 KB) (PDF 76 KB) Back to Top Medication/Pain Management Agreement for Use of Medication in Pain Management (Word 32 KB) (PDF 50 KB) Balancing Risk in the Management of Chronic Pain - Physician and Patient Toolkit (PDF 73 KB) Balancing Risk in the Management of Chronic Pain - Physician Book (PDF 3.5 MB) Clinical Policy for Use of Medication in Pain Management (Word 36 KB) (PDF 51 KB) Controlled Substance Prescription Receipt (Word 12 KB) (PDF 76 KB) Interagency Guideline on Opioid Dosing (PDF 212 KB) Lost or Stolen Prescription Attestation Form (Word 30 KB) (PDF 52 KB) Medication Error Self-Assessment Survey (Word 64 KB) (PDF 92 KB) Prescription Refill Policy (Word 16 KB) (PDF 408 KB) Sample Medication Form (Word 21 KB) (PDF 83 KB) Structuring Your Own Management of Pain - Patient Booklet (PDF 1.6 MB) Use Your SMARTS for Opioid Safety (PDF 200 KB) Back to Top Depositions & Witnesses Professional Witness Fee Agreement (Word 12 KB) (PDF 76 KB) Back to Top Quality Improvement (CQIP) Coordinated Quality Improvement Program Plan Template (Word 140 KB) Back to Top Patient SAFE Patient SAFE Medical Practice Toolkit (PDF 116 KB) Back to Top Employee-Related Issues Authorization for Release of Information Regarding Provider Professional Qualifications (Word 8 KB) (PDF 80 KB) Employee Confidentiality and HIPAA Training Acknowledgment Statement (Word 32 KB) (PDF 80 KB) Nonemployee Confidentiality and HIPAA Training Acknowledgment Statement (Word 32 KB) (PDF 80 KB) Back to Top Miscellaneous Fax Disclaimer Language (Word 8 KB) (PDF 76 KB) Back to Top Preprinted Forms Available in Quantity for Physicians Insurance Members In addition to the sample forms and letters, below, Physicians Insurance has also created some printed materials that members may order in quantity. Members may review, and then download or order these forms by going to our Printed Materials page. Answers About Anesthesia (PDF 1 MB) Chest Pain Evaluation Guideline and Documentation Tool (PDF 60 KB) Having A Healthy Baby (PDF 1.3 MB) How Are We Doing? Booklet (PDF 795 KB) Labor and Delivery: Choices & Decisions (PDF 1 MB) Medication Flowsheet (Word 49 KB) (PDF 4 KB) Patient Telephone Call Record (PDF 415 KB) Prenatal Health Questionnaire (PDF 204 KB) Prenatal Record Form (PDF 56 KB) Back to Top Back to Chapter 1: Communication and Rapport Chapter 2: Medical Records—Documentation and Release Chapter 3: Medical-Legal Issues Chapter 4: Patient Care Issues Chapter 5: Practice Management Issues Chapter 6: Treatment of Minors |
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