Forms and Sample Letters - Cogent, LLC

1 CHIROPRACTICF orms and Sample LettersAll Rights ReservedCopyright ON A BUTTON TO CHOOSE THAT SECTIONINTRODUCTION& GUIDELINESP ractice recordkeeping and effective use of the Forms and lettersTABLE OFCONTENTSL inks to copies of each form & letter , completed samples and instructionsALPHABETICALINDEXA lphabetical listing of all Forms and Letters with links to each copyCUSTOMIZABLEFORMSL inks to blank copies of each form or letter in a Microsoft Word formatCHIROPRACTIC Forms AND LETTERSINTRODUCTION& GUIDELINESC lick on a section below to view that information Introduction & Guidelines Recordkeeping and Use of Forms Rules of Recordkeeping Protection Strategy Checklist Correspondence Guidelines Managed Care Information Authors Notes & Disclaimer Copyright Information ReferencesMAIN MENUCHIROPRACTIC Forms AND LETTERSTABLE OF CONTENTSC lick on a category for a listing of available Forms and Letters Patient Forms Physical Exam Forms Insurance General Forms & Correspondence

2 Insurance Medicare Insurance Workers Compensation Diagnostic Forms Minors Forms & Letters Informed Consent & Authorizations Lab Requests Daily Notes Practice Forms Managed Care Compliance Patient Correspondence Professional Correspondence ReferencesMAIN MENUCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSPATIENT FORMSTo view a form from the listing, click on that form s title Patient Sign-In Sheet Patient Information Sheet Health History Checklist Confidential Case History Record Social History Sheet Patient s Job Description New Problem/Re-Evaluation form SOAP Notes Daily Progress Notes Progress Notes Alternative Style SOAP Notes Alternative Style Patient Satisfaction Survey Difficulty In Performing Activities Of Daily Living form Self-Help Activities form Financial Hardship Payment Agreement Hazard Warning form Exercise Instructions Home Care And Exercise Report Safety Belt Exemption letter Disability Certificate 2 Versions Physical Education Excuse letter 2 Versions Work/School Excuse Doctor s Appointment letter Patient Refusal To Allow X-Ray

3 letter Failure To Follow Advice letter To Parent/Guardian Of Minor ChildMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSPHYSICAL EXAM FORMSTo view a form from the listing, click on that form s title Physical Examination Legend/Key Physical Examination form Regional Examination form Cervical/Dorsal Regional Examination form Lumbar/Pelvis Pre-Employment Physical Examination letter (No Doctor-Patient Relationship Created) Physical Examination letter : Insurance IME (No Doctor-Patient Relationship Created) IME Examination Patient Report form Physical Examination letter : Athletics (No Doctor-Patient Relationship Created) Personal Injury QuestionnaireMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSINSURANCE FORMSTo view a form from the listing, click on that form s titleGENERAL Forms & CORRESPONDENCE Release Of All Claims letter To Patient When Insurance Company Rejects Claim letter To Insurance Company After Paper Review Insurance Assignment, Information Release And Payment Agreement Assignment.

4 Lien & Authorization To Release Medical Records & InformationMEDICARE Forms Medicare Explanation form Medicare Supplemental Carrier Protest LetterWORKERS COMPENSATION Forms Workers Compensation Authorization form Workers Comp History FormMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSDIAGNOSTIC FORMSTo view a form from the listing, click on that form s title Pregnancy Warning And Consent To X-Ray form Imaging Request Slip MRI History Sheet Imaging Interpretation form X-Ray Warning Labels Patient Refusal To Allow X-Ray LetterMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSMINORS - Forms & LETTERSTo view a form from the listing, click on that form s title Consent To Treatment (Minor)

5 letter Child Abuse/Neglect Report Failure To Follow Advice letter To Parent/Guardian Of Minor Child Work/School Excuse Doctor s Appointment letter Physical Education Excuse LetterMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSINFORMED CONSENT & AUTHORIZATIONSTo view a form from the listing, click on that form s title Informed Consent form Informed Consent To Chiropractic Treatment form Consent To Participate In Research Publication/Photo/Video Consent Authorization To Admit Observers Authorization To Use Patient Name In Newsletter/On Bulletin Board Authorization To Release Patient Information & Medical RecordsMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSAUTO ACCIDENT FORMSTo view a form from the listing, click on that form s title Personal Injury QuestionnaireMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSLAB REQUESTSTo view a form from the listing.

6 Click on that form s title Laboratory Request Slip Request For Cerebrovascular UltrasoundMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSDAILY NOTESTo view a form from the listing, click on that form s title Daily Notes form (SOAP Notes) Narrative Style Daily Notes form (SOAP Notes) Alternative Style SOAP Notes form Alternative Style Daily Telephone LogMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSPRACTICE FORMSTo view a form from the listing, click on that form s title Report Writing Checklist Daily Telephone Log Interview Checklist Substitute Or Associate Doctor Employment Interview Guidelines Employee Confidentiality Statement form Determining Independent Contractor Versus Employee Status form Credit Card Payment form Retirement Checklist Equipment Replacement Log Fax Transmission Cover Sheet Doctor s Request Records From Previous Doctor Patient s Request Records From Previous Doctor Response Patient s Or Provider s Request For Records Response Patient s Request For Records(Alternative Version) Response Other Provider s Request For Records Response Other Provider s Request For Records (No Patient Authorization)

7 Response Attorney s Request For Records Confirmation Doctor Declining To Accept Patient letter Advising Individual The Doctor Will Be Unable To Accept Him As A Patient Confirmation Patient Discontinued Care Voluntarily Confirmation Phone Message Discontinuing Care Failure To Follow Instructions Pre-Withdrawal letter Withdrawal LetterMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSREFERRAL FORMSTo view a form from the listing, click on that form s title Referral letter To MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSMANAGED CARETo view a form from the listing, click on that form s title Contract and Compliance letter Withdrawal from Network Contract and Compliance letter Reimbursement for Services not Covered by Contract Contract and Compliance letter Acknowledgement Back-Up Doctor Managed Care Coverage AgreementMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSCOMPLIANCETo view a form from the listing, click on that form s title Compliance Coding & Billing Compliance Audit Template Billing Compliance Investigation GuidelinesMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSPATIENT CORRESPONDENCETo view a form from the listing.

8 Click on that form s title Patient Not Satisfied And Will Not Return letter Follow-Up letter When Patient Does Not ComplyWith Referral Instructions Referral Thank You letter Thank You letter To Patient Who Sends Note Of Appreciation Apology letter Patient Kept Waiting Patient Re-Call letter Confirmation That Patient s Symptoms Are Being Addressed Collection letter version one Collection letter version two Collection letter version three letter Writing Off Debt Notice Of Associate Leaving Introduction Of New Associate letter Notice Of Sale/Retirement And Introduction Of New Doctor Notice Of Office Closing letter Of Condolence To Patient Seriously Injured During TreatmentMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSPROFESSIONALCORRESPONDENCETo view a form from the listing, click on that form s title Confirmation Of Telephone Call To Lawyer s Secretary Pre-Deposition letter To Patient s Lawyer Pre-Trial letter To Patient s Lawyer Transmittal letter Accompanying letter Of Protection letter Of Protection Irrevocable Instructions To Attorney To Pay Doctor letter To Attorney Who Fails To Honor Lein letter To Lawyer Seeking Status Report Of Malpractice Claim Team Physician Role Limitation letter Referral letter To MENURETURN TO TABLE OF CONTENTSCHIROPRACTICFORMS ANDLETTERSTABLE OFCONTENTSREFERENCESTo view a form from the listing.

9 Click on that form s title Assessment And Outcome Instruments and References Medicare 2000 New Information Medicare Regional OfficesMAIN MENURETURN TO TABLE OF CONTENTSCHIROPRACTIC Forms AND LETTERSALPHABETICAL INDEXC lick on a letter of the alphabet to view a listing of those formsTo view a form from the listing Click on that form s titleA Abuse Report Activities Of Daily Living Causing Problems Activities Of Daily Living Which HelpThe Patient Adjustment Log Advice Failure To Follow Advice Failure To Follow Parent Of Minor Child Advice Failure To Follow Warning letter Prior To Withdrawal Advice Failure To Follow X-rays Advice Symptom List, letter Apology Patient Kept Waiting Appointment Work/School Excuse When Keeping Dr s Assessment References Assignment Of Benefits Associate Introduction To Patients Associate Notice Of Leaving Athletic Examination Attorney Ignores letter Of Protection, letter To Attorney Instructions To Pay Doctor Attorney letter Of Protection Attorney Pre-deposition letter Attorney Pre-trial letter Attorney Request For Records.

10 Responding To Attorney Secretary letter Authorization Patient Name In NewsletterOr On Bulletin Board Authorization Release InformationAnd Medical Records Auto Accident Exam form Authors NoteBCDE-FG-HIJ-KLMN-OP-QRSTU-VWX-Y-ZAMA IN MENUCHIROPRACTIC Forms AND LETTERSALPHABETICAL INDEXC lick on a letter of the alphabet to view a listing of those titlesTo view a form from the listing Click on that form s titleB Bill Delinquent, Demand letter Bill Forgiveness Bulletin Board Consent To Use Patient Name OnACDE-FG-HIJ-KLMN-OP-QRSTU-VWX-Y-ZBMAIN MENUCHIROPRACTIC Forms AND LETTERSALPHABETICAL INDEXC lick on a letter of the alphabet to view a listing of those titlesTo view a form from the listing Click on that form s titleC Case History form Checklist Exercise Checklist Patient History Checklist Home Care Checklist Independent Contractors Checklist Interview Checklist Managed Care Checklist Checklist Protection Strategy Checklist Report Writing Checklist Retirement Checklist Risk Management Child Abuse / Neglect Report Child Consent To Treatment Child Parent s Failure To Follow Advice Clinical Lab Request Slip Collection