Sunday, March 26, 2017

CMA

CMA Sample Letters, Forms, Toolkits, Resources, Etc.

The following sample letters, forms, etc., are available free of charge to SDCMS-CMA member physicians. To access them, consult CMA’s California Physician’s Legal Handbook (CPLH) or download the respective CMA ON-CALL documents from CMA’s medical-legal library. For further assistance, contact SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.

Table of Contents:

ADA / Discrimination:

  • Rehabilitation Act Notice for Fewer Than Fifteen Employees (sample form)
  • Rehabilitation Act Notice for More Than Fifteen Employees (sample form)
  • Rehabilitation Act Grievance Policy Procedure (sample form)

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AIDS and HIV:

  • HIV Test Results (sample form authorizing disclosure)
  • HIV Antibody Test Laboratory Requisition Form (DHS 8257) (official form)
  • HIV/AIDS Confidentiality Case Report Form (DHS 8641A) (official form)
  • HIV/AIDS Confidentiality Case Report Form (DHS 8641P) (official form)
  • For My Patients: Taking the HIV Test
  • HIV Test: Patient Pamphlet (DHS 8682 Perinatal) (information and consent form)

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Allied Health Professionals:

  • Medical Assistant Training Certification (sample letter)
  • Physician Responsibility Protocol and Delegation of Services Agreement

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Ancillary Services:

  • Sample Information Request Letter to Investigator

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Business Prohibitions / Disclosure Requirements:

  • Disclosure of Financial Interests (sample)

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Consent:

  • Minor’s Self-sufficient Status (sample documentation form)
  • Minor Caregiver’s Authorization (sample affidavit)
  • Minor’s Medical Treatment (sample authorization for agent to consent)
  • Breast Cancer Poster (“Be Informed” poster in three languages)
  • Prostate Cancer Poster (“Be Informed” poster in three languages)

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Drug Prescribing / Dispensing:

  • Controlled Substance Profile (sample physician request for patient activity report)
  • Drug Substitution (sample letter to health plan protesting)
  • Drug, Nonformulary (sample letter to health plan requesting authorization)
  • Drug, Non-approved Use (sample letter to health plan requesting authorization)
  • Drug, Formulary Restrictions (sample letter to patient explaining)
  • Medication Errors Reporting Program Form
  • Pain Medications (sample notice of opiate prescription)
  • Pain Medications (sample notice of deemed approval)

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E-medicine / HIPAA:

  • HIPAA Business Associate Agreement (sample form)
  • HIPAA Business Associate Agreement (sample Security Rule addendum)
  • HIPAA Business Associate Agreement (CMA standing agreement with members)
  • HIPAA Notice of Privacy Practices (sample notice)
  • HIPAA Notice of Privacy Practices (sample acknowledgement of receipt)
  • HIPAA Notice of Privacy Practices (sample acknowledgement tracking information)
  • HIPAA Privacy Policy Statement (sample policy)
  • HIPAA Transaction Rule Compliance (sample letter to software vendor)
  • HIPAA Transaction Rule Compliance (sample letter to billing service)
  • HIPAA Transaction Rule (PrivaPlan TCS vendor survey tool)
  • Telemedicine Consent (sample form)

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Expert Witness Issues:

  • Expert Witness Retention Agreement in Civil Cases (sample contract)

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Forgoing Treatment:

  • Advance Healthcare Directive (sample forms and instructions)
  • Advance Healthcare Directive Registration Form
  • Do-Not-Resuscitate (DNR) (CMA/EMSA-approved pre-hospital form)
  • CPR: A Guide to Cardiopulmonary Resuscitation for Patients and Their Families

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Fraud and Abuse: Referral Issues:

  • Professional Courtesy Policy

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Managed Care: Overview:

  • Office Audit of Sensitive Medical Information (sample letter)

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Managed Care: Contract Termination / Exclusion:

  • Nonpayment (sample termination notice)
  • IPA Contract Repudiation/Cancellation (sample confirmation letter)
  • Patients Notification of Physician’s Termination of Plan (sample letter)
  • Inadequate or No Notice Provided to Patients and/or Physicians (sample letter)
  • Fair Hearing to Challenge Decision to Terminate/Exclude (sample request)
  • Reason for Termination/Exclusion (sample request)
  • Reinstatement/Inclusion (sample request)
  • Adverse Impact on Physician-Patient Relationship (sample paragraph)
  • Malpractice Claim (sample paragraph)
  • 805 Report (sample paragraph)
  • Medical Board Probation (sample paragraph)
  • Termination Due to Quality of Care Advocacy (sample paragraph)
  • Filing a Dispute With a Health Plan or Its Contracted Medical Group/IPA (sample paragraph)
  • Unlawful Discrimination (sample paragraph)
  • Lack of Access to Terminated/Excluded Physician’s Specialty (sample letter challenging)
  • Retraction (sample demand letter)
  • Untrue Information Regarding Quality Problem (sample paragraph)
  • Untrue Information Regarding Retirement (sample paragraph)
  • Explaining Termination/Exclusion to Patient (sample letter)
  • Patient Protest (sample letter to plan/IPA)
  • Patient Demand to Stay With Terminated or Nonparticipating Physician (sample letter to plan/IPA)
  • Employer/Union/Other Plan Sponsor (request from patient for assistance)
  • Physician Colleagues (sample letter for assistance)
  • Physician Colleague (sample request of plan/IPA for reconsideration)
  • Failure to Receive Referrals/Defamation (sample letter to plan challenging)

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Managed Care: Utilization Review and Management:

  • Standing Referral to Specialist Request (sample form)
  • Medical Necessity Denial (sample appeal letter)
  • Medical Necessity Denial (sample documentation form)
  • Medical Necessity Denial (sample patient refusal of treatment form)
  • Hospital Discharge Within Forty-eight (48) Hours of Vaginal Delivery or Ninety-six (96) Hours of Cesarean Section (sample patient consent form)
  • Hospital Discharge Within Forty-eight (48) Hours of Vaginal Delivery or Ninety-six (96) Hours of Cesarean Section (sample physician authorization form)
  • Economic Profiling Information (sample request for)

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Medical Board — Reports:

  • Medical Board Report Form: Investigation of Impaired Physician, Initial and Final

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Medical Practice — Employment Issues:

  • Schedule C: Physician Leaving Group (sample notification letter to patient)
  • Family and Medical Leave (model physician certification form)
  • Covering Physicians (sample letter requesting authorization to bill for)
  • Retirement (sample letter notifying patients)
  • Transfer Medical Records (sample authorization form)
  • Whistleblower Laws (sample form)

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Medical Practice — Groups, IPAs, MSOs:

  • Arbitration Provision, Model Managed Care Contract (sample provision)
  • Sample Articles of Incorporation
  • Consultant Agreement (sample)
  • Request for Proposal (sample)

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Medical Records — Management:

  • Authorization to Release Medical Records (sample notice to patient of noncompliant form)
  • HIPAA Accounting of Disclosure Tracking Form
  • Facsimile Transmittal Form

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Medical Records: Requests for Access:

  • Evidence Code §1158 Request (sample form)
  • Authorization to Release Medical Records (sample notice to patient of noncompliance form)
  • Settlement Offer or Demand (sample authorization for disclosure in connection with)
  • Pre-employment and Employment Physicals Cover Sheet
  • Patient Access to Health Information (sample request form)
  • Authorization for Use or Disclosure of Protected Health Information (sample form)
  • Responding to a Subpoena (checklist)
  • Affidavit to Accompany Subpoenaed Medical Records (sample form)
  • Subpoena: Authorization for Disclosure of HIV Test Results (sample form)
  • Subpoena: Invalid Deposition Subpoena for Business Records (sample response)
  • Subpoena: Privacy Notice to the Patient (sample form)
  • Subpoena: Authorization for Disclosure Pursuant to Subpoena (sample form)

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Medical Records — Special Confidentiality Requirements:

  • Patient Request That Certain Information Be Withheld (sample response letter)
  • Immunization Information (sample disclosure form)

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Medicare and Medi-Cal:

  • Freedom of Information Act (sample letter)
  • Medicare Advantage or Medicaid Product (sample letter requesting opt-out of Blue Cross of California product)
  • Medicare Advantage (sample patient notification of non-acceptance of PFFS plan)
  • Medicare Beneficiary (sample private contract with physician)
  • Medicare Beneficiary (sample affidavit for physician opting out of Medicare)

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OSHA / Office Safety:

  • Hazardous Substance Communication Program Compliance checklist
  • DEA (registrants inventory of drugs surrendered) (DEA-41)
  • Sharps Injury Log (sample copy)

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Outpatient Facilities / Surgicenters:

  • Outpatient Surgery (patient transfer reporting form)
  • Outpatient Surgery (patient death reporting form)

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Peer Review:

  • Peer Review Confidentiality (sample response to Medical Board request for information without subpoena)

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Physician-Patient Relationship:

  • Practice Relocation (sample notice to patient)
  • Transfer of Medical Records (sample authorization form)
  • Termination of Health Plan Participation (sample notice to patient)
  • Physician-Patient Relationship — Taking an Active Role in Your Healthcare
  • Physician-Patient Relationship — Patient Safety: A Guide for Physicians
  • Physician-Patient Relationship — A Physician’s Guide to Tracking and Communicating Test Results
  • Physician-Patient Relationship (sample termination letter)

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Professional Liability:

  • Unsolicited Diagnostic Test Results (sample letter declining to review)
  • Unanticipated Outcome Disclosures (clinician’s checklist)
  • Unanticipated Outcome Disclosures (medical group administrator’s checklist)
  • Harassment (sample policy prohibiting)

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Reimbursement: From HMOs and Other Private Payors:

  • RICO Settlement Step-by-Step External Billing Dispute Procedure (Aetna/CIGNA)
  • RICO Settlement Step-by-Step External Billing Dispute Procedure (Blue Cross/HealthNet)
  • RICO Settlement Step-by-Step Compliance Dispute Procedure (Aetna/CIGNA)
  • RICO Settlement Step-by-Step Compliance Dispute Procedure (Blue Cross/HealthNet)
  • RICO Settlement Aetna Compliance Claim Form
  • RICO Settlement CIGNA Compliance Claim Form
  • RICO Settlement Blue Cross Compliance Claim Form
  • RICO Settlement HealthNet Compliance Claim Form
  • Assignment of Benefits (sample form)
  • Assignment of Benefits Rejection (sample notification letter to patient)
  • Medicare COB Payment Complaint Form
  • Emergency Services (sample demand for payment by contracting physician)
  • Emergency Services (sample demand for payment from Knox-Keene plan by noncontracting physician)
  • Late Payment (demand for payment of emergency service claims with interest)
  • Late Payment (sample letter demanding payment of non-emergency service claims with interest)
  • Noncontracting Physician (sample cover letter)
  • Patient Responsibility for Payment of Services (sample agreement)
  • Noncontracting Physician (sample demand letter for full payment for emergency services)
  • Payment of Claim With Interest Where IPA or Other Contracting Entity Has Failed to Pay (sample demand letter from contracting physician)
  • Payment Denial After Treatment Authorization or Verification of Eligibility (sample demand letter)
  • Payment Denial (sample request for explanation of)
  • Payment Denial for Lack of Medical Necessity (sample appeal of)
  • Payment Denial for Failure to Comply With Technical Billing Requirement (sample appeal of)
  • Plan Requirements That Patients Travel to Use Outside Service (sample letter protesting)
  • Overpayments (sample letter of refusal to reimburse alleged)
  • Payments Made in Error (sample letter of refusal to reimburse)
  • “Silent PPOs”: Declining to Be Included on Any List Conveyed to Payors That Does Not Actively Encourage Enrollee Use of Contracted Providers (sample letter)
  • “Silent PPOs”: Challenging Discount Due to Lack of Contract (sample letter)
  • “Silent PPOs”: Challenging Discount Because Patient Not Covered by Contract Granting Discount (sample letter)
  • “Silent PPOs”: Challenging Discount on Grounds That Contract Did Not Authorize Conveyance (sample letter)
  • “Silent PPOs”: Challenging Discount Amount (sample letter)
  • “Silent PPOs”: Challenging Discount Access by Discount Health Plan (sample letter)
  • “Silent PPOs”: Request for Summary of All Payors Eligible to Claim Discount (sample letter)
  • “Silent PPOs”: Notice of Termination of Physician Participation Agreement (sample letter)
  • “Silent PPOs”: Challenging Evidence of Discount Entitlement Supplied by Payor (sample letter)
  • “Silent PPOs”: Demand for Notification, Accounting and Disgorgement for Illegal Discounting (sample letter)

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Reimbursement — From Patients:

  • Noncovered Services (sample notice of patient responsibility for)
  • Patient Agreement to Pay for Noncovered Services (sample form)
  • Patient Financial Responsibilities (sample form)
  • Collection Following Bounced Check (sample physician demand for payment)
  • Collection Following Stopped Check (sample physician demand for payment)

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Reimbursement — Other Issues:

  • Lien Involved (sample letter to defense attorney)
  • Lien Agreement (sample agreement)

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Reporting Abuse:

  • Sexual Assault Examination Form — Forensic Medical Report Acute (< 72 hours) Adult/Adolescent OES, Division of Emergency Services 923 (official reporting form)
  • Sexual Assault Examination Form — Forensic Medical Report Acute (< 72 hours) Child/Adolescent OES, Division of Emergency Services 930 (official reporting form)
  • Sexual Assault Examination Form — Forensic Medical Report Acute (< 72 hours) Child/Adolescent OES, Division of Emergency Services 925 (official reporting form)
  • Sexual Assault Examination Form — Forensic Medical Report OES, Division of Emergency Services 950 (official reporting form)
  • Child Abuse Report Form SS-8572 (employee acknowledgement form)
  • Elder and Dependent Adult Abuse (official reporting form of suspected) (SOC 341)
  • Elder and Dependent Adult Abuse Reporting Requirements — Employee Acknowledgement (sample form)
  • Elder and Dependent Adult Abuse and Neglect Examination (official forensic medical report)
  • Suspicious Injury Report (OES 920) (official reporting form)
  • Domestic Violence Examination (OES 502) (official reporting form)

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Reporting Diseases, Conditions, and Events:

  • Voluntary Declaration of Paternity
  • Alpha Fetoprotein Tests (DHS 4453) (sample form)
  • Confidential Case Report of a Birth Defect (DHS 4427) (sample form)
  • Workers’ Compensation — Doctor’s First Report of Occupational Injury or Illness (DLSR 5021) (official form)

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Reproductive Issues:

  • Sperm (sample waiver of repeat testing forms)
  • Sperm Reactive for Hepatitis B, Hepatitis C, or Syphilis (sample consent to use)
  • Hysterectomy Consent (sample form)
  • Sterilization Consent Form — Federally Funded PM 330 (English)
  • Sterilization Consent Form — Federally Funded PM 330 (Spanish)
  • Sterilization Consent Form — Nonfederally Funded PM 284 (English)
  • Sterilization Consent Form — Nonfederally Funded PM 284 (Spanish)

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Workers' Compensation:

  • Workers’ Compensation Downcoding MLFS (sample letter protesting)
  • Workers’ Compensation (Application for Spinal Surgery Second Opinion Physician List) (DWC Form 232)
  • Workers’ Compensation Downcoding OMFS (sample letter protesting)
  • Workers’ Compensation — Declaration of Readiness to Proceed to Expedited Hearing (trial) (official DWC Form 4)
  • Workers’ Compensation (application for adjudication of claim)
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