Confidential Patient Information Sheet

This form in conjunction with the Case History sheet is designed to make it simple to collect the needed history from the patient. This sheet would serve as your new intake sheet to gather the pertinent patient information.

This sheet also possesses the appropriate language that protects the patient’s rights through ERISA and helps to ensure reimbursement. You do not want to change the information at the bottom of this form.

This form should be used in conjunction with the Case History Sheet which can be found by CLICKING HERE

Informed Consent Forms

The OSCA recommends that you check with your malpractice insurance provider first.

Some insurance providers recommend that you use a form; others recommend that you verbally inform the patient and document the conversation in your notes. A sample form is linked above!

Evaluation & Management (E/M) Services Guidelines 2021

Exam Form

This EXAM form was create to enable the provider to meet the various requirements of both Medicare PARTand the different levels of E/M requirements of AMA.

Explanation and Template for Appealing E/M Denials

Guidance on how to appeal an insurance E/M Denial. Sample letter to send to insurance companies.

Financial Hardship Form

HIPAA Sheet

(Revised for September 23, 2013 Deadline)

This HIPAA sheet was created to minimize the confusion with HIPAA regulations. It is a simple one sided sheet that highlights the issues that are relevant to the average chiropractic office. It is recommended that you print off 4 – 5 of these and have them laminated to reduce the amount of printing you do in your office. You would simply hand the laminated copy to the new patient on their initial visit and should they request a copy you would provide them with one at that time.

This form should be used in conjunction with the Terms of Acceptance Sheet which can be found by CLICKING HERE

Insurance Verification Sheet

One of the most frustrating tasks a staff person has to do is verify insurance. Typically when all is said and done you have just spent the last 35 minutes becoming more and more frustrated with the information you were given. In the end you are conditioned to dread the call.

Verifying insurance is a pivotal part of the patient process. We need accurate information to convey back to the patient. This Insurance Verification Form was created to help you ask the right questions. It is laid out efficiently and able to be modified.

For a more detailed explanation of how to use this form CLICK HERE to download the instruction sheet.

New Patient Phone Interview

Patient Waiver of Coverage

This form was created in light of the new insurance world where co-pays and deductibles are higher than ever. In many cases it is more affordable for the patient to receive care based on your time of service rates rather than their co-pay and deductible schedule. But you must be careful, if you are a provider with said insurance company you are contractually obligated to bill for all services rendered to that patient. That is UNLESS the patient waives the use of their insurance, thus the creation of this wavier.

It is important that you explain to the patient they are waiving all coverage. This means they cannot submit the charges to eat up a deductible. This form essentially means they do not have coverage.

Prepayment Agreement

SOAP Note

One of the most frequent questions we receive is what should be in a SOAP note. When you consider there are so many variables from payer to payer it does make it difficult to create the “perfect” format. We believe we have done this. We realize this format may not work for everyone but it does hit all of the elements you need to satisfy all payer types INCLUDING Medicare.

You will need to spend some time editing this form as it may not have all the procedures you perform in your office on it. It is given to you in word format so you can edit it. You will need to add or remove any services you do or do not do in your office as well as add your name at the bottom of each record for signature requirements.

It is important to understand that this SOAP note MUST work in conjunction with the Treatment Plan document we have provided you as well. Together they will can prove medical necessity, alone they proving nothing!

Terms of Acceptance

This form was created to help condense all the various documents that end up in a patient record. We have found over time that simplifying the patient paperwork is so very powerful to the flow of the office. This document helps to cover things like Informed Consent, Consent to treat minors, Consent to X-ray and more. Very good form! This should be given to every new patient along with the Confidential Patient Information Sheet.

This form should be used in conjunction with the HIPPA Sheet which can be found by CLICKING HERE

Treatment Plan

The key to medical necessity is ultimately the treatment plan. After reviewing 100’s of insurance guidelines and Medicare Guidelines we have come up with this document. It was designed to simplify the process of communicating your clinical intent with both the patient and payers.

This form should be completed at every Evaluation and Re-Evaluation. It should only take you about 2 minutes to complete once you have become familiar with it.

URAC Appeal Letter

Often times a doctor will complain about the way they have been treated in a review process. Their first thought is to sue and fight for their right to practice. That course of action often times does not work and ends up wasting a considerable amount of resources. The OSCA is taking another approach. We want to learn the rules and use them to force other parties within the healthcare system to follow them.

This letter is a step in that direction. URAC is a credentialing agency that governs the review process of healthcare in the US. They require certain activities before denying care. It is a wonderful agency and we plan to use them to fight for patient rights. This letter helps you to communicate to the payer the requirements under their certification.

For a full set of instruction on how to use this letter CLICK HERE. 

Use this letter and enjoy the benefits of following the rules!!!!

X-Ray Release Form

This is a standard X-Ray Release form to be used when patients request their films.