O & P

Clinical and Business Forms

2007 Update

American Orthotic and Prosthetic Association

Since 1917

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Disclaimer

AOPA offers these forms as examples only and does not presume that this Forms book is an exclusive inventory of all suitable forms for the O&P industry. Purchasers of this publication are entitled to modify, delete text or otherwise change any of these forms to suit their specific needs. AOPA provides no guarantee that the forms contained herein are acceptable to any specific payer or that the forms meet the necessary criteria for billing, receiving payment or documenting “medical necessity.” Users of these forms are responsible for any actions as a result of their use, whether or not the forms were altered from the version appearing in the book. AOPA does not assume any liability for the use of forms contained herein. This book offers a number of forms that were obtained directly from either the Department of Health and Human Services (HHS) or the Centers for Medicare and Medicaid Services (CMS) and those forms are so noted.

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Table of Contents

Introduction ix

Part 1 – Clinical Practice and Patient Forms Section A – Patient Processing Forms A-1 HIPAA Forms 1

HIPAA Notice of Privacy Practices 2 HIPAA Acknowledgement of Receipt of Notice 10

A-2 Facility Information Forms 11

Statement of Quality of Care 12 Patient Bill of Rights 13 Patient Sign-In Sheet 14 Welcome Letter 15 Patient Service Agreement 16 Patient Acknowledgement Form 17

A-3 Insurance and Patient Information Forms 18

Insurance Verification Form 19 Patient Information Form 21 Application for Medicare Co-Insurance Waiver 23 Pre Authorization Waiver 24 Notice of Exclusion from Medicare Benefits 25 Advance Beneficiary Notice 26 Advance Notice - No Authorization 27 Precertification 28

A-4 Consent and Authorization Forms 29

Appointment of Representative 30 Medical Authorization 32 Statement to Permit Payment of Medicare Benefits 33 Photographic Consent Form 34 Information Release Form / Signature on File 35 Consent for Treatment of Minor Child 36

A-5 Financial and Payment Policy Forms 37

Patient Information and Financial Policy 38 Patient Service and Financial Policy 39 Acknowledgement of Patient Service and Financial Policy 42 Patient Financial Obligation Estimate 43 Payment Plan Charges Agreement 44 Promissary Agreement 45

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Company Billing Policy 46 Financial Policy for Patients with Insurance 47 Credit Card Authorization 48 Automatic Bank Draft Agreement 49

Section B – Clinical Forms B-1 Initial Patient Evaluation Forms 50

Patient History 51 Patient Treatment Notes 53 Orthotic Evaluation Form 55 Orthotic Initial Evaluation Form 56 Prosthetic Initial Evaluation Form 57 Pedorthic Patient Profile 58 Orthotic/Prosthetic Notes 59 Walk/Align Fitting Form 60 Patient Rehabilitation Potential 61

B-2 Patient Chart Notes 62

Orthotic-Prosthetic Services Patient Chart Notes 63 Patient Progress Record 64 SOAP Note Format 65 Chart Card 66

B-3 Patient Measurement Forms 67

Symes/Chopart Measurement Chart 69 Transtibial Measurement Chart 70 Transfemoral Measurement Chart 71 Hip Disarticulation Measurement Chart 72 Lower Extremity Orthometry 73 BKA / Lower Extremity Orthometry 74 Lower Extremity Prosthetic Measurement (version 1) 75 Lower Extremity Prosthetic Measurement (version 2) 76 Lower Extremity Prosthetic Measurement (version 3) 77 Lower Extremity Prosthetics 78 Lower Extremity Prosthetic Information 79 Prosthetic Measurement Chart 80 Lower Limb Prosthetic Measurement Form 81 Above Knee Prosthetic Measurements 82 Prosthetic Information - Above Knee Prosthesis 83 Below Knee Prosthesis Measurement 85 Upper Extremity Prosthetic Measurement 87 Upper Extremity Prosthetic Information 88 Biomechanical Examination 89 General Orthotic Measurements 91 Lower Extremity Orthotics 92 Lower Limb Orthometry 93 Lower Limb Orthotic Measurement Form 95 Lower Extremity Order/Measurement (AFO) 96

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Lower Extremity Order/Measurement (FO) 97 Patient’s Foot Measurements/Information 98 Shoe Form 99 Orthotic Foot Evaluation 100 Diabetic Foot Evaluation 101 Hand Orthosis Measurement 102 Arm & Shoulder Orthosis Measurement 103 Universal Spinal Measurement 104 Spinal Orthosis Measurement Form 105

Section C – Post-Visit & Follow-up Forms C-1 Patient Follow-up Forms 106

Notification of Appointment 108 Delivery Form 109 Verification of Receipt of Services 110 Pedorthic Acknowledgement 111 Care and Use of New Prosthesis 112 Test Fitting and Delivery Checklist 113 Care and Use of Rigid Spinal Brace 115 Care and Use of Your AFO 116 KAFO Use and Care Instructions 117 Halo and Halo Vest Use and Care Instructions 118 Corset Use and Care Instructions 119 Lumbro Sacral Corset 120 Body Jacket Use and Care Instructions 121 Wrist Hand Orthosis Use and Care Instructions 122 UCBL Foot Orthotic Use and Care Instructions 123 U.C.B. Instructions 124 Foot Orthotic (Arch Support) Use and Care Instructions 125 Letter about New Products 126 Soft Foot Insert Instructions 127 Patient Care Guidelines for Shoes 128 Patient Care Guidelines for AFO & KAFO 129 Patient Care Guidelines for Scoliosis Orthosis 130 Patient Care Guidelines for Custom Foot Orthoses 133 Patient Instructions Foot Orthoses 134 Guidelines for Skin Care/Diabetic Foot Care 136 Molded Shoes (information letter) 138 Orthosis “Breaking-In” Instructions 139 Suggested Wearing Schedule 140 General Patient Information 141 Care Plan – AFO 142 Plastic AFO Use and Care 143 Patient Instructions AFO or KAFO 145 Plastic KAFO Use and Care 146 Patient Instructions Custom Knee 147 Patient Instructions Fracture Bracing 148 Care Plan TLSO 149 Patient Instructions Spinal Orthosis 150

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Applying Neoprene Garments 151 Hip Abduction Orthosis Use and Care Information 152 Instructions for Wearing New Pedorthic Devices 153

C-2 Forms for Referring Physician 154

Statement of Certifying Physician for Therapeutic Shoes 155 Verbal Order to Provide Services 156 Orthotic Prescription 157 Prosthetic Prescription 158 Request for Clinical Information 159 Notification of Delivery Letter 160 Patient Evaluation Letter to Referring Physician 161 Physician Referral / Consultation Record (version 1) 162 Physician Referral / Consultation Record (version 2) 163 Referral Request on Behalf of Patient 164

C-3 Facility Internal Patient Forms 165 Facility Call/House Call 166 Work Order 167 Quality Assurance Form 168 Component Sheet 169 Record of Pedorthic Devices 170 Lab Instructions 171

Section D – Other Miscellaneous Forms D-1 HIPAA Forms 172

HIPAA Patient Authorization 173 HIPAA Request for Restriction on Use / Disclosure of PHI 174 HIPAA Request for Confidential Communication 175 HIPAA Request to Access PHI 176 HIPAA Facility’s Decision on Patient’s Request to Access PHI 177 HIPAA Medical Record / Billing Record Amendment / Correction Form 178 HIPAA Facility’s Decision on Patient’s Request to Amend Record 180 HIPAA Form for Accounting of Disclosures of PHI 181 HIPAA Patient Complaint Form 182 HIPAA Patient Complaint Log 183

D-2 Medicare Appeals Forms 184

Medicare Redetermination Request 185 Medicare Reconsideration request 186 Request for Medicare Hearing by Administrative Law Judge 187

D-3 Patient Satisfaction/Complaint Forms 189 Patient Complaint / Comment Form 190 Patient Service Evaluation 191 Patient Satisfaction Survey (version 1) 192 Patient Satisfaction Survey (version 2) 193

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Patient Survey 194 Physician Satisfaction Form 195 Payer/Case Manager Satisfaction Form 196 Component / Product Failure Report 197

Customer Feedback Letter 198

Part 2 – Office Administrative Forms

Section E – Patient Billing and Reimbursement Forms 199

Waiver of Payment Due to Economic Hardship 200 Billing Letter 201 Payment Agreement 202 Installment Payment Agreement 203 Promissory Note 204 Payment Reminder Letter 205 Past Due Letter (version 1) 206 Past Due Letter (version 2) 207 Past Due Letter (version 3) 208 Past Due Letter (version 4) 209

Section F – Office Accounting Forms 210

Billing Document Checklist 211 Worksheet for Charges 212 Procedure Code Sheet 215 Patient Ledger 216 Day Sheet 217 Monthly Sales/ Accounts Receivable 218 Patient Encounter Form 219 Patient Visit Summary Form 220 Item Summary Form 221 Credit Memo 222 Cash Reconciliation 223 Daily Credit Card Report 224 Daily Service Journal 225 Cash Receipt Journal 226 Check Receipt Journal 227 Patient Account Status 228 Record of Professional Orthotic Services 229 Component Request Form 230 Request to Make Adjustments, Write-offs Form 231

Section G – Other HIPAA Forms 232

Business Associate Contract 233 Employee Training – HIPAA Rules 242

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Section H – Personnel Forms 243 Acknowledgement of Receipt of Compliance Policy 245 Notice of Right to COBRA 246 Computer Password 247 New Employee Orientation 248 Patient Confidentiality (employee form) 249 Incident Report - Employee 250 Incident Report - Non Employee 252 Team Member Incident Report 254 Occurrence Report 256 Accident Report 257 Employee Status 258 Transfer Form 260 Prosthetist Evaluation Form 261 Prosthetic Supervisor Evaluation Form 265 Prosthetic Technician Evaluation Form 269 Orthotist Evaluation Form 273 Orthotic Supervisor Evaluation Form 277 Orthotic Technician Evaluation Form 281 Orthotic Assistant Evaluation Form 285 Initial Employment Form (version 1) 289 Initial Employment Form (version 2) 290 Resignation Questionnaire 291 Confidential Termination Report 292 Authorization and Release for Drug and Alcohol Screen 293 Verification of Blood Borne Pathogen Training 294 Hepatitis B Vaccination form 295 Mileage Expense Report 296 Business Trip Expense Report 297

INDEX: 299