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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).

Forms & Checklists

  • Compliance Plan Sample Compliance Plan for Physician Practice (Format: Word): Modify and implement this sample compliance plan in your medical practice.
  • 5 Steps to PECOS Enrollment (Format: Word): If your practice has not yet enrolled with PECOS, here’s a comprehensive information guide and checklist for accomplishing this important task.
  • Request for Form W-9 (Format: Word): If you make payment or payments to a vendor during the year that will require you to send an IRS Form 1099-MISC to that vendor, then you need to obtain an executed Form W-9 from the vendor before or soon after making payments.
  • Physician Practice Merger Due Diligence Workbook (Format: Excel): Due diligence is the most important part of the physician merger process. Use this workbook to assemble and analyze data and information on each participating medical practice.
  • Managed Care Information Summary Sheet (Format: Word): Use this form to summarize all of the requirements for each of your managed care relationships. This form should be accompanied by each related provider agreement and kept in a notebook for easy access.
  • Managed Care Contract Negotiation Questionnaire (Format: Word): Use this questionnaire to define your leverage and document the benefit(s) you bring to a provider network before you begin negotiating with a managed care payer.
  • Action Item Worksheet (Format: Excel): Need a way to track and document progress on your physician practice action items? If so, use this handy little worksheet.
  • Payer Negotiation Matrix (Format: Excel): When negotiating managed care contracts, use this matrix to keep track of your contacts, discussions, and notes with the payers. Examples provided.
  • Medical Practice Merger Implementation Checklist (Format: Word): If you are participating in a physician practice merger, use this checklist to review and discuss a variety of merger issues.
  • Strategic Planning Input Form (Format: Word): Before conducting your strategic planning retreat, use this form to survey the practice physicians, providers, clinical staff, and administrative staff. Use the replies to help formulate your retreat agenda.
  • Monthly Financial Analysis Worksheet (Format: Excel) Use this worksheet to track your physician practice financial performance. Add additional benchmarks you want to track.
  • Compensation Questionnaire (Format: PDF) Use this questionnaire to find out what your physicians think about your current physician compensation formulary.
  • Bad-debt Control Checklist (Format: PDF) Checklist you can use to assess whether or not a medical practice is prepared to minimize its bad debts.
  • Employee Time Off Request Form (Format: Word): Use this form to document an employee’s request for time off from the medical practice.
  • Managed Care Payer Analysis Worksheet (Format: Excel): Use this simple worksheet to review the Gross Collection %, A/R, and the Days in A/R for your top payers. Also use it to grade non-financial payer issues.
  • Payer Reimbursement Comparative Worksheet (Format: Excel): Use this simple worksheet to compare reimbursement for your top CPT codes and also to compare current reimbursement to Medicare rates.
  • Patient 10 Day Collection Letter (Format: MS Word): Quit using multiple patient statements; send this letter out after the first statement to improve patient collections.
  • Managed Care Negotiation Checklist (Format: MS Word): use this handy checklist when negotiation or renegotiating a managed care relationship.
  • Managed Care Contract Review Checklist (Format: MS Word): use this checklist to review managed care contracts.
  • Evaluation and Management Coding Analysis Worksheet for Group Practice (Format: MS Excel): use this worksheet to compare E/M coding patterns for physicians in a group practice. Can be used to identify undercoding and overcoding situations.
  • Checklist for Starting Up a New Medical Practice (Format: MS Excel): provides a list of essential tasks that must be performed prior to launching a medical practice in checklist format, including columns for “person responsible” and date started and completed.
  • Cash Flow Projection Worksheet (Format: MS Excel): a worksheet you can use to project revenues and expenses for a medical practice; uses physician utilization figures to project revenues.