Office Forms

Every office needs basic forms to establish a patient relationship. Patient forms capture necessary insurance information, health history and contact details. Forms also serve an important role in defining the patient relationship, including documenting informed consent, communicated expectations and patient understanding regarding the practice. Below are samples of common forms and their objective. Be sure to check your state, specialty and licensing board for any additional required patient forms.

1. Patient Information Sheet (CLICK HERE)
   
   • Captures patient name, address, contact, insurance and other important information.
   • Provides authorization for the practice to bill the patient’s insurance company.
   • Communicates patient’s financial responsibilities to the practice.
2. Patient Health History (CLICK HERE)
   
   • Captures additional patient demographic, pharmacy and medication information.
   • Lists patient’s medications and supplements.
   • Identifies family history, social and immunization history.
3. Protected Health Information (PHI) Consent Form (CLICK HERE)
   • Captures how patient would like PHI to be shared by the practice.
   • Documents patient agreement of how to share PHI.
4. Financial Policy Agreement (CLICK HERE)
   • Provides details of practice’s financial policy, including billing processes and fees.
   • Provides obligations of the practice and patient.
   • Documents patient agreement to financial policy and obligations.
5. Patient Rights and Responsibilities (CLICK HERE)
   • Informs patient of rights related to patient care.
   • Informs patient of responsibilities related to patient care.
   • Documents patient agreement to rights and responsibilities.
6. Telemedicine Informed Consent (CLICK HERE)
   • Informs patient of the use of telemedicine.
   • Documents authorization from patient to participate in telemedicine.
7. Long-Term Controlled Substances (CLICK HERE)
   • Informs patients of long-term controlled substance policies.
   • Documents patient agreement with long-term controlled substance policies.
8. Patient Acknowledgement of Notice of Privacy Practices (CLICK HERE)
   • Documents patient acknowledgement of receiving Notice of Privacy Practices.
   • Requires practice to provide Notice of Privacy Practices.
   • HHS provides a Notice of Privacy Practices (CLICK HERE)
9. Adjunct Therapy Notice (CLICK HERE)
   • Informs patient of adjunct therapies utilized by the practice.
   • Documents patient agreement of adjunct therapy use.
10. Patient Agreements Notice (CLICK HERE)
    
    • Informs patients that practice provides cash-pay services requiring additional agreements.
    • Documents patient acknowledgement of additional patient agreements.
11. Specialty Lab Tests Notice (CLICK HERE)
    
    • Informs patients that practice recommends specialty lab testing.
    • Documents patient acknowledgement of specialty lab testing use.
    • Each specialty lab may require their on ABN.
12. Acute Care Notice (CLICK HERE)
    • Informs patients when practices do not provide acute care or urgent care.
    • Documents patient acknowledgement of practice’s scope of services. 

Providers should have patients complete any additional forms relevant to their specialty, such as:

1. Nutritional Supplement Consent
2. Potential Environmental Exposure
3. Functional Medicine Timeline
4. Patient Readiness Assessments
5. Patient Experience and Expectations
6. Patient Diet History
7. Other Screening Forms