FORMS & CHECKLISTS

On this page you will find forms, checklists and spreadsheets useful for starting up and managing a medical practice. Read the brief description following the document title for guidance on using the document.

To access any document, (1) right click with your mouse on the hyperlinked document title, (2) click “Save Target As” from the pop-up box, (3) save the file to your desktop, and (4) open the file in the appropriate application (either Excel or Word).

• Health Plan Assessment Matrix (Format: Excel): provides a matrix to perform a side-by-side comparison of health plans with respect to such benchmarks and criteria as collection rates, timely payment and more. If you have questions concerning how to use this matrix kindly contact reedt@rtacpa.com.
• Medical Practice Review Program (Format: MS Word): an actual work program that allows you to conduct a financial and operational assessment of a medical practice.
• Sample Medical Practice Budget (Format: Excel): sample worksheet to assist in the budgeting process.
• Record Retention List (format: MS Word): provides guidance on how long to retain medical office records, both financial and clinical.
• Sample Practice Management Report (Format MS Excel): use this worksheet to summarize and manage vital practice data, including charges, collections, adjustments, collection ratios, accounts receivable agings, and clinical encounters.
• Evaluation and Management Coding Analysis for Solo Medical Practice (Format MS Excel): use this worksheet to analyze E/M coding patterns for solo physician practitioner. Can be used to identify undercoding and overcoding situations.
• Dashboard Indicators (Format MS Excel): use this worksheet to summarize medical practice benchmarks; also can be used as a financial management tool.
• Monthly Production and Collection Budget Worksheet (Format MS Excel): use this worksheet to track actual monthly production and collections against related budgeted figures. Best used in conjunction with a “bottom up” budgeting process.
• Medical Practice Office Relocation Checklist (Format: Excel): handy worksheet to use when moving a medical practice to new office space.
• Valuation of Call Coverage (Format: Excel): used to value call and reduce compensation when a physician decides to remove himself from call coverage schedule
• Medical Practice Employee Survey Form (Format: MS Word): used to obtain feedback from practice employees
• Waiting Time in Reception Area Worksheet (Format: MS Word): use this form if a practice wants to analyze patient waiting times in the receiption area; an excellent patient satisfaction detection tool.
• UCR Response Letter (Format: MS Word): if a charge is ever reduced by a payer because of “usual, customary, and reasonable” considerations, use this letter to send to a patient explaining UCR.
• Medical Practice Employee Time Off Form (Format: MS Word): use this form when an employee wants to request time off from the medical practice.
• Patient Insurance Verification Form (Format: MS Word): use to verify and document a patient’s insurance coverage.
• Denial Tracking Sheet (Format: Excel): a worksheet you can use to document and track why charges are being denied; excellent management and monitoring tool.
• Patient Satisfaction Form (Format: MS Word): use this form to get feedback from your patients
• Doctor Meeting Agenda Format (Format: MS Excel): use this form to create and document your physician meeting
• Pediatric Surgical Associates IRS Case (Format: MS Word): summary of important tax case applicable to any C-Corporation group practice.
• Medical Practice Administrator Job Description (Format: MS Word): sample job description for physician practice admininstrator
• Notice to Patients after Contract Termination (Format: MS Word): sample letter to send to patients after a managed care contract is terminated
• Managed Care Contract Termination Letter (Format: MS Word): use this simple letter to send notice of contract termination
• Sale of Medical Practice Checklist (Format: MS Excel): use this checklist when selling a medical practice
• Medical Practice Merger Implementation Checklist (Format: MS Word): simple checklist to use when merging medical practices
• Billing and Collection Questionnaire (Format: MS Word): use this questionnaire to summarize and analyze the billing and collection process
• Physician Consultation Request Form (Format: MS Word): Use this form to request (and document) consultation by another physician
• Patient Termination Letter (Format: MS Word): Use this form to terminate the physician/patient relationship. However, be sure to also check with your malpractice carrier to see if it has its own suggested termination letter
• Annual Administrator Performance Review Form (Format: MS Word): Use this form to grade out an administrator’s performance and use to as a basis for a bonus
• IRS 96 CPE Text (Format: PDF): This is an excerpt from the IRS education text for the Exempt Organization Division related the valuation of physician medical practices.
• Internal Control Checklist (Format: MS Word): Use this checklist to perform a review of a medical practice’s internal controls.
• HIPAA Notice of Privacy Practices (Format: MS Word): Use this form to notify patients of office HIPAA privacy practices.
• A Strategic Planning Self-Assessment for Healthcare Professionals (Format: MS Word): The purpose of this self-assessment is to give you a concise checklist of best practices in a clinical practice.
• Patient No Show Tracking Worksheet (Format: MS Excel): Use this simple worksheet and related graph analysis to track no show appointments.
• Monthly Stat Summary (Format: MS Word): Use this simple form to report monthly physician practice management statistics to management.
• Statement of Financial Responsibility (Format: MS Word): Sample patient payment responsibility form
• Revenue Cycle Reporting for Medical Practice (Format: PDF): Use this form to monitor, analyze, and benchmark your revenue cycle process.
• Medical Practice Demerger Checklist (Format: PDF): Use this checklist in case a medical practice merger does not work out and a practice wants to pull out.
• Insurance Payment Turnaround Worksheet (Format: PDF): Here is a worksheet you can use to quantify how quickly, on average, you are getting paid by third party payors. You can mix in multiple payors or just analyze a single payor. The benchmark is 30-45 days on average. If you are above 45 days, investigate your collection processes.
• Process to Renegotiate a Managed Care Contract (Format PDF): Here is a step-by-step guide on what you should do when attempting to negotiate or renegotiate a managed care relationship.
• Strategic Planning Assessment Checklist (Format PDF): This checklist is a strategic planning self-assessment you can use in your practice. The purpose of these self-assessments is to give you a concise checklist of best practices in a clinical practice. This checklist follows the Pareto Principle of focusing on the 20% of business practices that get you 80% of the results.
• Medical Employee Questionnaire (Format PDF): Employees see what is going on each and every day – get their feedback on how your medical practice is running, how they are being treated, and ideas to improve the office. Here is the one I use to ensure their responses will remain confidential.
• Medical Practice Strategic Planning Outline (Format PDF): Conducting a strategic planning meeting for a medical practice? Here is a handy outline to use as a starting point.