New patient forms for a medical practice

I just finished developing my general housekeeping policies and forms.  Like everything else, you don’t have to invent the wheel.  I referenced online templates and forms from my residency to create versions tailored to my practice philosophy.

Notice of Privacy Practices

It looks like the Notice of Privacy Practices has been a HIPAA mandate since April 2003.  You’ve probably seen this form before, but never really paid any attention to it.  I know I didn’t. This policy explains how practices may use or disclose patients’ protected health information to carry out treatment, payment, health care operations, etc.  It also describes patients’ rights regarding how they can access, restrict, or amend  their protected health information.  Finally, it gives instructions on how to file complaints regarding the privacy practices.

Given that this policy is required by law, I didn’t think I had too much leeway for literary expression.  I ended up using the Notice of Privacy Practices provided by the AMA, which was 7 pages long.  I trimmed it down to 4 pages by changing the wording and removing redundant examples without altering the core message of the policy.

Acknowledgement of Notice of Privacy Practices

In conjunction with the Notice of Privacy Practices, patients will need to sign a form acknowleding that they  understand and accept this policy, thereby, consenting to the use and disclosure of their protected health information.

Financial Agreement and Assignment

This form describes your practice’s payment policies, such as patient payment reponsibilities, refraction charges, late charges, pre-authorization or referral requirements, returned check policies, etc.  Also included is an authorization to reassign reimbursement benefits to the practice, which allows insurance companies to pay you directly.  Finally, I described how patients would be financially responsibile for denied services.  Some insurance companies will require you to have a previously signed consent on file for this purpose.  For Medicare, if you think services may be denied (i.e. Avastin injections for DME), you’ll need to have patients sign an Advanced Beneficiary Notice (ABN) ahead of time informing them of such possibility.  Otherwise, you won’t be allowed to charge patients denied claims.

Patient Information Sheet

This one’s self explanatory.  This form asks patients to fill out their demographics, insurance information, emergency contacts, primary care or referring physician name, etc.

Medical History Form

Since I won’t be using a technician, I wanted to make this form as comprehensive as possible, so that I could minimize my history taking time.  For the past medical history, I listed all potentially relavent medical conditions that patients would check off if applicable.  I included all my social history questions in this section as well.  For past ocular history, I did the same thing, but also included symptoms.  I made a separate contact lens history section also.  For the past surgical history, oral medications, eye drops, and allergies, I just made it free response.  Finally, for family history, I listed the relevant conditions for patients to check off as well.  The whole thing ended up being just under 2 pages.  I like it.

Authorization of Release of Medical Records

For this one, I made two forms: one for release to my practice, and another for release from my practice.  For the release to my practice form, I made check boxes with the following:

☐The entire medical record, excluding mental health, alcoholism, drug abuse, and HIV/acquired immune deficiency syndrome (AIDS) treatment records

☐Mental health treatment records

☐Alcoholism Treatment Records

☐Drug Abuse Treatment Records

☐Laboratory Reports

☐Imaging Reports

☐Operative Notes


I also included a section to specify date ranges.

I’m not sure if you’re supposed to use a lawyer to create these forms, but I didn’t.  For the most part, they all pretty much say the same thing as most other practices’ forms, so I should be OK.  I still need to make a couple more forms, including informed consent forms and referral forms,  but the ones above should be enough to complete the initial patient registration process.

E-mail me if you want to take a look at my forms. (Howie’s note: Or just go to his or my website and click on new patient forms! I just used another practice’s forms and adopted it to my office.)

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