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.  

How to Guide

Find advice and tips on the best use of the Sample Forms. Documents are in Word format and easy to customize for your practice needs.

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• 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)