Letters and Templates

Advanced Beneficiary Notice (ABN) - An ABN is a standardized notice provided to Medicare patients to inform them of medical necessary services that may not be covered by Medicare.

• The Texas Attorney General adopted a standard authorization to Disclose Protected Health Information form as required by Section 181.154(d) of the Act.
• The TMA created a sample authorization form to disclose protected health information.

Business Associate Agreement - The TMA offers a sample Business Associate Agreement (BAA). Have legal counsel review before use.

Credit Card Authorization Policy Form - Before storing credit card information, please be aware of HIPAA and other regulatory agencies requirements outlined in this Medical Economics article.

Confidentiality Agreement for Employees - Sample employee confidentiality agreement from Physician Practice.

Consent Forms (expand Rules and Regulations) - The Texas Medical Disclosure Panel adopted the following form which shall be used to provide informed consent to a patient or person authorized to consent for the patient of the possible risks and hazards involved with the procedure. For out-of-state patients, also consider having them sign an agreement that states Texas law governs in the event of a dispute or lawsuit. The Texas Alliance For Patient Access has language that can be used to develop such an agreement for emergency and non-emergency care.

• Patient Right to Restrict Use or Disclosure of PHI (Sample Form)
• Patient Right to Restrict Use or Disclosure of PHI(Sample Policy)

Mobile Device Use Agreement - Physicians Practice developed a mobile device use agreement to help reduce HIPAA violations.

Payment Plan Agreement - Physicians Practice developed the above patient plan agreement as a template for physicians.

Termination Letter - TMLT sample templates for patient termination letters.

Texas Standardized Prior Authorization Request Form for Prescription Drug Benefits - The Texas Department of Insurance adopted a rule creating a standard form that physicians can use to request prior authorization of prescription drug benefits from the health plan. The form was updated May 2022 to streamline the process for authorizing requests for continuation of therapy.

Texas Standard Prior Authorization Request Form for Health Care Services - The Texas Department of Insurance adopted a rule creating a standard form that physicians can use to request prior authorization for Health Care Services.