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.


Authorization to Disclose Protected Health Information

 

Business Associate Agreement

 

Credit Card Authorization Policy Form - Physicians Practice developed this free credit card authorization form, for physicians to customize to fit their practice needs.

 

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

 

Consent Forms - 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 thpatient of the possible risks and hazards involved with the procedure.

 

HITECH Non-Disclosure

  • Sample policy - Regarding Patient Right – Restrict Use or Disclosure of PHI 
  • Sample Form -Regarding Patient Right - Restrict Use or Disclosure of PHI 
 

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 new rule went into

effect September 1, 2015.

 

Texas Standard Prior Authorization Request Form for Health Care Services - Texas Department of Insurance adopted a rule creating a standard form that physicians canuse to request prior authorization for Health Care Services. The newrule goes into effect September 1, 2015.