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Downloadable Forms

Sample Event/Complaint Report

Instructions for Completing an Event/Complaint Report

Sample Discharge Letter (pdf format)
      Editable Word format

Patient Satisfaction Survey

Staff Self Evaluation

In-Office Telephone Record

Telephone Call Log

Patient Agenda

Office Visit Follow-up Instructions

Communication Poster (English)

Communication Handout (English)

Communication Poster (Spanish)

Communication Handout (Spanish)

Request for Consultation

Consultation Log

Diagnostic Test Tracking Log

Follow-up Appointment Log

Anticoagulation Log

Employee Confidentiality Policy & Agreement

HIPAA Compliant Authorization

Informed Refusal

Informed Consent for Clinical Trials

Sample Informed Refusal Letter to Patient (pdf format)
      Editable Word format

Sample Letter to Insurance Carrier for Refusal to Authorize Payment (pdf format)
      Editable Word format

Patient Information Update

Documentation Checklist

Signature Log

Release of X-Rays

Medication Flowsheet

Sample Medication Log (1 page)

Sample Medication Log (2 page)

911 Poster

RACE Fire Diagram

Medical Equipment Tracking Log

© Copyright 2012 Princeton Insurance. All Rights Reserved.
RISK MANAGEMENT GUIDELINES FOR THE OFFICE PRACTICE: March 2006 - Revised February 2012

The Guidelines are neither intended to provide legal advice, nor to serve as a professional standard. The contents are only for purposes of information and education.

Healthcare law is complex and highly regulated. The law changes frequently and because these changes can be significant, you should always check with appropriate professionals to stay fully abreast of the current laws that impact the delivery of healthcare services.