Private Practice Playbook: Sample forms

The Private Practice Playbook: Sample Forms Appendix (PDF) is a collection of templated forms for independent physician practices that address patient, employee and administrative needs.  

• Advanced Beneficiary Notice (ABN) (DOCX)
• Benefits Assignment (DOCX)
• Health Plan 101 (PDF)
• HIPAA Privacy Forms (DOCX)
• Notice of Privacy Practices (DOCX)
• Notice of Privacy Practices Acknowledgment Form (DOCX) 
• Patient Demographics (DOCX)
• Patient Health History (DOCX)
• Surprise Billing Acknowledgment Form (PDF)
• Telehealth Consent Form (DOCX)

• Medical Record Release–Inbound (DOCX)
• Practice Financial Policy (DOCX)
• Patient Payment Plan (DOCX)
• Price List (DOCX)
• Request to Amend/Change Medical Record (DOCX)

• Daily Patient Payments (DOCX)
• Fax Cover Page (DOCX)
• Key Receipt Acknowledgment (DOCX)
• Medication Log (DOCX)
• Patient Sign-In Sheet (DOCX)
• Policy Template (DOCX)
• Refund Request (DOCX)
• Visitor Log (DOCX)

• Employee Performance Review (DOCX)
• Employee Warning Template (DOCX)
• Expense Reimbursement (DOCX)
• Time Off Work Request Form (DOCX)
• Job Descriptions
  • Billing (DOCX)
  • Clerical (desk/reception) (DOCX)
  • Clinical (DOCX)
  • Practice manager (administrator) (DOCX)
• New Hire Documents
  • Authorization for Payroll Deduction (DOCX)
  • Confidentiality Agreement (DOCX)
  • Drug Screen Consent (DOCX)
  • Employee Handbook Acknowledgment Form (DOCX)
  • Employee Vaccination Record Request (DOCX)
  • New Hire Checklist (DOCX)