April 17, 2018

Template Signs & Forms

Disclaimer: These documents are templates only. They do not reflect the requirements of your state’s laws. You should consult with advisors (e.g., your state or local medical or specialty society, or legal or other counsel) familiar with your state’s privacy laws prior to using these documents. The meddkit team does not provide legal advice. Any documentation used in compliance with HIPAA, your state’s, municipality’s or federal laws should be reviewed with an attorney.

COVID-19 Waiver Template

COVID-19 has put tremendous strain on the United States healthcare system. It’s important to remind patients to take precaution before putting you or those who you care for at risk. This template reminds patients to wear masks, sanitize hands and declare any COVID-19-like symptoms or contact.

Enter your email to receive an editable copy of the COVID-19 Waiver Template.

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Editable Stop Sign Template

editable stop sign template screenshot

This sign alerts your patients about important reminders or actions. It can be attached to the inside and outside of your exam rooms and office.

The default verbiage can be edited easily in Microsoft Word. It reads:

  • Face mask on?
  • Hands sanitized?
  • Follow-up scheduled?

Enter your email to be sent your editable template. Check your spam folder if you can’t find it!

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No-show, Late Arrival and Late Cancellation Policy Template

No-shows, late arrivals and late cancellations can ruin your practice’s financial stability. You should be upfront with your patients and clients about your policy for these delinquencies. You want to minimize their occurrence and also mitigate their impact on your other patients.

Enter your email to get meddkit’s proposed No-show, Late Arrival and Late Cancellation Policy template. Be sure to modify it to account for your fee(s).

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screenshot of text messaging consent form

We have provided a sample paper form that you can use to provide proper consent to texting (and emailing) your patients. Be sure to insert your practice name.

It is easier to provide this disclosure electronically. Contact us if you would like help with that.

Enter your email to be sent your editable template. Check your spam folder if you can’t find it!

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Patient Portal Enrollment Template

Patient Portal Enrollment Form thumbnail

We have also created a sample form that you can use to gather patient portal enrollments your patients. This template states what the purpose of the patient portal is and the features that it offers.

Be sure to insert your practice name and the services that your patient portal offers to your patients or clients. Simply change the red text.

Contact us if you would like help with providing and electronic copy of this form, with optional e-signature or consent box.

Once again, enter your email to be sent your editable template. Check your spam folder if you can’t find it!

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Notice of Privacy Practices Template

HIPAA asks that you provide a Notice of Privacy Practices to your patients to explain to patients how you will use their Protected Health Information (PHI). This notice also reviews a patient’s privacy rights with respect to their personal health information. 

This document should be visible to patients in your office and provided in print or electronic format upon request. You can read more about HIPAA’s requirements for your Notice of Privacy Practices on the Department of Health and Human Services’ website.

Enter your email to get your editable template. This Notice of Privacy Practices is based on the DHHS template. This version includes extra provisions to contacting patients electronically in order to grow your practice.

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General Authorization for Release of PHI Template

You may already have a Notice of Privacy Practices as required by HIPAA. This document may not allow you to communicate electronically with patients for marketing your practice. In this case, you will want new and existing patients to complete a specific General Authorization Form.

A General Authorization Form will allow you to release PHI to a specific third-party, like meddkit, for a specific purpose. Enter your email to get your editable template.

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