< Back Sample Office Documents Practice Management Online features a collection of sample office documents that your practice can review to assist in developing materials for your own office. See also Sample Personnel Documents. Find more Documents & Forms in the Practice Toolbox Jump down to: - Infant Forms - Missed Appointments - Office and Patient Encounter Forms - Retail-based Clinics - Well Child Forms Infant Forms Back to top Four Month Preventive Care Questionnaire Questionnaire provides key questions to ask at the 4-month preventive care visit. Areas covered are nutrition, sleep, development, elimination, safety, and mother and family issues. Newborn Follow-Up Sample form created in 2004 provides key questions, procedures, and documentation for the newborn follow-up visit. Nine Month Preventive Care Questionnaire Questionnaire provides key questions to ask at the 9-month preventive care visit. Areas covered are nutrition, sleep, behavior, safety, and mother and family issues. Sample New Baby Insurance Card Provides a sample of a "New Baby Insurance Coverage" card for pediatricians to give to families as a reminder to inform insurance carriers of a new baby needing health care coverage. Six Month Preventive Care Questionnaire Questionnaire provides key questions to ask at the 6-month preventive care visit. Areas covered are nutrition, sleep, behavior, safety, and mother and family issues. Two Month Check Handout provides information to parents on what is covered at the 2-month preventive care visit. It provides detail on what is important regarding the baby's development, nutrition, safety, and immunizations. Two Month Preventive Care Questionnaire Questionnaire provides key questions to ask at the 2-month preventive care visit. Areas covered are nutrition, sleep, development, elimination, safety, and mother and family issues. Missed Appointments Back to top Appointment Policy Sample office document alerting families of appointment policies. Missed Appointment Letter (First and Second) This sample letter can be used or modified to be sent those families who do not call or show for their first and/or second scheduled appointments. Missed Appointment Letter (Third) This sample letter can be used or modified to be sent those families who do not call or show for their third scheduled appointment. Missed Appointment Policy This sample missed appointment policy can be used and/or adapted to meet the needs of your practice. Office and Patient Encounter Forms Back to top Pediatric Care Online Point-of-Care Tools for Practice Pediatric Care Online, the premier resource for pediatric point-of-care information from the American Academy of Pediatrics, has teamed up with Practice Management Online to offer newly compiled and adapted tools for practice such as forms, questionnaires, and fact sheets to help in efficient delivery of pediatric care. A Parent’s Guide to Benefits This sample flyer provides patient families with basic information regarding benefit plans, including well child care policy, adding/dropping dependants, life insurance, and other important topics. To be posted in the pediatric office setting. Asthma Visit Form This sample form can be used when caring for children who have asthma. Care Coordination Request Form This sample form is used by the pediatrician to request care coordination. Claim Correction Form Sample form that includes pre-printed fields typically used when correcting claims submitted to a payer. Includes fields such as plan information, diagnostic codes, CPT codes, and general administrative errors to be corrected. Co-Payments This is a sample office document that can be given to parents and guardians who are unable to make a co-payment for their visit. Consultation Request Form Sample form provides format with key pieces of information required for an effective referral to specialty care and proper follow-up with the patient. Developmentally Based Fall Precautions A sample office checklist outlining precautions to take in order to prevent falls. Over 20 precautions are listed, categorized for infants and for all patients. Early Intervention Program Referral Form This sample office document can be used when referring a patient to an early intervention program. Emergency Information Form for Children With Autism This sample office document can be completed for children who have autism. Happy New Insurance Year This sample flyer provides a reminder for patients to review the date their insurance card renews and encourages patients to fully understand co-pays, pharmacy benefits, and referral requirements for their plans. To be posted in the pediatric office setting. Health Form Policies This is a sample document that can be given to parents and guardians on the policy for completing school forms. Health Savings Account Card Authorization This sample document can be used or modified for those families who have health savings accounts. Hearing and Vision Screening This sample policy can be used or modified alerting families of your hearing and vision screening policy. Illustrations of Situations Requiring/Not Requiring Authorization Sample list of situations illustrating when your practice must obtain patient authorization to disclose protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Improving Claims Processing and Payment: A Self-Assessment Tool for Physicians/Providers The following set of questions can be used to assist physicians/providers in better understanding the processes used within their own practice to submit and track claims, and to discover opportunities for improving those processes for the purpose of improving payment and accounts receivable. Local List of Possible Community Resources for Pediatric Practices This sample office document can be used to provide families with the names and contact information of local referral sources and family groups so that the information is readily available when needed. Log to Track Disclosures of PHI Sample form for practices to track non-TPO disclosures of a patient's protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Medical Home Care Coordination Measurement Tool Tool provides ways to collect patient level data on care coordination services provided, the time required to provide the services, the complexity of the patient's needs, and the outcome resulting from the intervention. Medical Home Practice-Based Care Coordination Workbook Published by the Center for Medical Home Improvement (CMHI) with an aim to develop, implement and evaluate care coordination in a medical home as part of an improvement process. Notice of Privacy Practices Sample office document for Notice of Privacy Practices to post and distribute to patients, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Office Financial Policies These sample office financial policies can be used and/or adapted to meet the needs of your practice. Overall Requirements for Coding an Established Patient Visit This document provides an overview of when it is appropriate to code for 99211, 99212, 99213, 99214, and 99215. Overview of Today's Visit: Sample Form This sample document can be used by front office staff on all patients upon checking in to ensure that all administrative needs are handled by the appropriate staff and not the pediatrician. Pardon Our Dust—Our Office Is Going Electronic This info sheet may be displayed in your office or copied as a patient handout. It will explain to your patients and their parents what your EHR implementation means for them. Parental Refusal to Vaccinate Form This form may be used as a template for vaccine refusal but should not be considered a legal document and should not substitute for legal advice from a qualified attorney. Patient Authorization for Use and Disclosure of Protected Health Information Sample form for obtaining authorization from patients to use and/or disclose protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Patient Complaint Form Sample form for patients who wish to complain about your practice's privacy policies and procedures, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Patient Education on Billing Issues This document provides an overview to patients on how insurance companies are billed. Patient Encounter Form - Sample Superbill Form for Multi-provider Practice Sample superbill form provides list of CPT codes, diagnoses, and other key fields needed using scannable form. This sample comes from a multi-provider practice. Patient Survey This sample document can be used or modified to ask patient's about their satisfaction with their office visit. Physician Care Management Tool used to measure physician care plan monitoring activity. Includes fields such as time spent on phone calls, care conferences, reviewing labs, test results, and general care plan oversight. Pre-Visit Contact Form This sample form can be filled out by parents in preparation for their child's next office visit. Privacy Officer’s Incident Event Log Sample form for the practice's Privacy Officer to track complaints and monitor compliance with the HIPAA Policy Rule, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Questions and Answers about Vaccine Ingredients This article provides an overview of which ingredients are in vaccines. Receipt of Notice of Privacy Practices Written Acknowledgement Form Sample form for obtaining written acknowledgment from patients that they have received a copy of the official Notice of Privacy Practices, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Registration Form for Patients With Special Health Care Needs This sample form can be used to register a patient who has special health care needs. The form can be adapted as needed. Request for an Accounting of Certain Disclosures of Protected Health Information for Non-TPO Purposes Sample form for patients who request an accounting of non-TPO disclosures of their protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Request for Correction/Amendment of Protected Health Information Sample request form for patients who wish to correct or amend their protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Request for Limitations and Restrictions of Protected Health Information Sample request form for patients who wish to restrict how their protected health information is used or disclosed, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Request to Inspect and Copy Protected Health Information Sample request form for patients who wish to inspect and copy their protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Sample ADHD Medication Monitoring Form Sample form that offices can use to help monitor their patients' ADHD medication regimen. Sample Care Plan Oversight (CPO) Billing Sheet Form This form provides a template for tracking care plan management by patient using regularly used CPT codes. Sample E-mail Disclaimer Addressing HIPAA Concerns The following e-mail is a sample. It is intended to provide some warning if the wrong or an unintended person receives private health information. Sample Information Card for Unimmunized Patients This sample office document can be provided to patients who are not immunized. It can be used to inform any health care provider caring for a child that the child is not immunized against certain diseases. Sample Privacy Policies Sample list of privacy policies for developing and implementing policies related to protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Sample Privacy Procedures Sample list of privacy procedures to be used for developing and implementing procedures related to protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule. Sick Visit Sample This sample document can be used as a template for sick child visits. Supplies Needed to Start a Practice This checklist includes 3 sample lists of the various supplies needed to start a medical practice. Tab 1 outlines the medical office supplies, tab 2 the equipment, and tab 3 the office supplies needed. The Childhood Immunization Schedule: Why Is It Like That? This article provides information about the vaccine schedule. The Importance of Immunizing Children: A Sample Practice Policy This sample office document provides a practice's policy on vaccinating their patients and can be adapted or modified to fit the needs of your practice. This was first presented in AAP News May 2008. The Medical Home Family Index Survey This is a companion tool to the Medical Home Index: Measuring the Organization and Delivery of Primary Care for Children with Special Health Care Needs and is intended for use with a cohort or families whose children have special health care needs The Medical Home Index: Measuring the Organization and Delivery of Primary Care for Children with Special Health Care Needs This is a validated self-assessment and classification tool to translate the broad indicators defining the medical home into observable, tangible behaviors and processes of care within any setting. Tool C: Choices of Billable Telephone Care This sample checklist can be used to guide discussion among members of your practice to determine which telephone visits would warrant a fee. This is part of the AAP's Payment for Telephone Care: A Toolkit. Tool G: Sample Office Sign Sample office sign alerting patients of a new policy for charging for telephone visits. This is part of the AAP's Payment for Telephone Care: A Toolkit. Tool H: Sample Office Answering Message Sample language for answering service messages alerting patients of the option of telephone visits as well as potential charges. This is part of the AAP's Payment for Telephone Care: A Toolkit. Tool I: Sample Staff Scripts Sample language for staff and pediatrician alerting patients/families of a fee for telephone visits. This is part of the AAP's Payment for Telephone Care: A Toolkit. Tool K: Sample Telephone Documentation Form Version 1 This sample document can be used to note telephone visits and guide the pediatrician on how to charge for the visit. This is part of the AAP's Payment for Telephone Care: A Toolkit. Tool L: Sample Telephone Documentation Form Version 2 This sample document can be used to note telephone visits and guide the pediatrician on how to charge for the visit. This is part of the AAP's Payment for Telephone Care: A Toolkit. Tool M: Sample Care Plan Oversight Documentation Version 1 This sample document can be used to chart care oversight and length of time provided. This is part of the AAP's Payment for Telephone Care: A Toolkit. Tool N: Sample Care Plan Oversight Documentation Version 2 This sample document can be used to chart care oversight and length of time provided. This is part of the AAP's Payment for Telephone Care: A Toolkit. Tool T: Nurse Telephone Encounter Documentation This sample document can be used to document nurse telephone care. This is part of the AAP's Payment for Telephone Care: A Toolkit. Retail-based Clinics Back to top Retail-based Clinics Office Flyer This sample fact sheet provides families with a discussion of the myths and facts of retail-based clinics (RBCs). Well Child Forms Back to top Well-Child Visit Form Sample #1 This sample document can be used for well-child visits. Well-Child Visit Form Sample #2 This sample document can be used for well-child visits.