CHIROPRACTIC INTRODUCTION & GUIDELINES TABLE OF CONTENTS ALPHABETICAL INDEX CUSTOMIZABLE FORMS. Forms and Sample Letters

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1 CHIROPRACTIC Forms and Sample Letters INTRODUCTION & GUIDELINES Practice recordkeeping and effective use of the forms and letters TABLE OF CONTENTS Links to copies of each form & letter, completed samples and instructions ALPHABETICAL INDEX Alphabetical listing of all forms and letters with links to each copy CUSTOMIZABLE FORMS Links to blank copies of each form or letter in a Microsoft Word format CLICK ON A BUTTON TO CHOOSE THAT SECTION All Rights Reserved Copyright 2000.

2 CHIROPRACTIC FORMS AND LETTERS INTRODUCTION & GUIDELINES Click on a section below to view that information Introduction & Guidelines Recordkeeping and Use of Forms Rules of Recordkeeping Protection Strategy Checklist Correspondence Guidelines Managed Care Information Authors Notes & Disclaimer Copyright Information References MAIN MENU

3 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS Click on a category for a listing of available forms and letters Patient Forms Physical Exam Forms Insurance General Forms & Correspondence Insurance Medicare Insurance Workers Compensation Diagnostic Forms Minors Forms & Letters Informed Consent & Authorizations Lab Requests Daily Notes Practice Forms Managed Care Compliance Patient Correspondence Professional Correspondence References MAIN MENU

4 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS PATIENT FORMS To view a form from the listing, click on that form s title Patient Sign-In Sheet Patient Information Sheet Health History Checklist Confidential Case History Record Social History Sheet Patient s Job Description New Problem/Re-Evaluation Form SOAP Notes Daily Progress Notes Progress Notes Alternative Style SOAP Notes Alternative Style Patient Satisfaction Survey Difficulty In Performing Activities Of Daily Living Form Self-Help Activities Form Financial Hardship Payment Agreement Hazard Warning Form Exercise Home Care And Exercise Report Safety Belt Exemption Letter Disability Certificate 2 Versions Physical Education Excuse Letter 2 Versions Work/School Excuse Doctor s Appointment Letter Patient Refusal To Allow X-Ray Letter Failure To Follow Advice Letter To Parent/Guardian Of Minor Child MAIN MENU RETURN TO TABLE OF CONTENTS

5 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS PHYSICAL EXAM FORMS To view a form from the listing, click on that form s title Physical Examination Legend/Key Physical Examination Form Regional Examination Form Cervical/Dorsal Regional Examination Form Lumbar/Pelvis Pre-Employment Physical Examination Letter (No Doctor-Patient Relationship Created) Physical Examination Letter: Insurance IME (No Doctor-Patient Relationship Created) IME Examination Patient Report Form Physical Examination Letter: Athletics (No Doctor-Patient Relationship Created) Personal Injury Questionnaire MAIN MENU RETURN TO TABLE OF CONTENTS

6 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS INSURANCE FORMS To view a form from the listing, click on that form s title GENERAL FORMS & CORRESPONDENCE Release Of All Claims Letter To Patient When Insurance Company Rejects Claim Letter To Insurance Company After Paper Review Insurance Assignment, Information Release And Payment Agreement Assignment, Lien & Authorization To Release Medical Records & Information MEDICARE FORMS Medicare Explanation Form Medicare Supplemental Carrier Protest Letter WORKERS COMPENSATION FORMS Workers Compensation Authorization Form Workers Comp History Form MAIN MENU RETURN TO TABLE OF CONTENTS

7 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS DIAGNOSTIC FORMS To view a form from the listing, click on that form s title Pregnancy Warning And Consent To X-Ray Form Imaging Request Slip MRI History Sheet Imaging Interpretation Form X-Ray Warning Labels Patient Refusal To Allow X-Ray Letter MAIN MENU RETURN TO TABLE OF CONTENTS

8 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS MINORS - FORMS & LETTERS To view a form from the listing, click on that form s title Consent To Treatment (Minor) Letter Child Abuse/Neglect Report Failure To Follow Advice Letter To Parent/Guardian Of Minor Child Work/School Excuse Doctor s Appointment Letter Physical Education Excuse Letter MAIN MENU RETURN TO TABLE OF CONTENTS

9 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS INFORMED CONSENT & AUTHORIZATIONS To view a form from the listing, click on that form s title Informed Consent Form Informed Consent To Chiropractic Treatment Form Consent To Participate In Research Publication/Photo/Video Consent Authorization To Admit Observers Authorization To Use Patient Name In Newsletter/On Bulletin Board Authorization To Release Patient Information & Medical Records MAIN MENU RETURN TO TABLE OF CONTENTS

10 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS AUTO ACCIDENT FORMS To view a form from the listing, click on that form s title Personal Injury Questionnaire MAIN MENU RETURN TO TABLE OF CONTENTS

11 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS LAB REQUESTS To view a form from the listing, click on that form s title Laboratory Request Slip Request For Cerebrovascular Ultrasound MAIN MENU RETURN TO TABLE OF CONTENTS

12 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS DAILY NOTES To view a form from the listing, click on that form s title Daily Notes Form (SOAP Notes) Narrative Style Daily Notes Form (SOAP Notes) Alternative Style SOAP Notes Form Alternative Style Daily Telephone Log MAIN MENU RETURN TO TABLE OF CONTENTS

13 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS PRACTICE FORMS To view a form from the listing, click on that form s title Report Writing Checklist Daily Telephone Log Interview Checklist Substitute Or Associate Doctor Employment Interview Guidelines Employee Confidentiality Statement Form Determining Independent Contractor Versus Employee Status Form Credit Card Payment Form Retirement Checklist Equipment Replacement Log Fax Transmission Cover Sheet Doctor s Request Records From Previous Doctor Patient s Request Records From Previous Doctor Response Patient s Or Provider s Request For Records Response Patient s Request For Records (Alternative Version) Response Other Provider s Request For Records Response Other Provider s Request For Records (No Patient Authorization) Response Attorney s Request For Records Confirmation Doctor Declining To Accept Patient Letter Advising Individual The Doctor Will Be Unable To Accept Him As A Patient Confirmation Patient Discontinued Care Voluntarily Confirmation Phone Message Discontinuing Care Failure To Follow Pre-Withdrawal Letter Withdrawal Letter MAIN MENU RETURN TO TABLE OF CONTENTS

14 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS REFERRAL FORMS To view a form from the listing, click on that form s title Referral Letter To M.D. MAIN MENU RETURN TO TABLE OF CONTENTS

15 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS MANAGED CARE To view a form from the listing, click on that form s title Contract and Compliance Letter Withdrawal from Network Contract and Compliance Letter Reimbursement for Services not Covered by Contract Contract and Compliance Letter Acknowledgement Back-Up Doctor Managed Care Coverage Agreement MAIN MENU RETURN TO TABLE OF CONTENTS

16 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS COMPLIANCE To view a form from the listing, click on that form s title Compliance Coding & Billing Compliance Audit Template Billing Compliance Investigation Guidelines MAIN MENU RETURN TO TABLE OF CONTENTS

17 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS PATIENT CORRESPONDENCE To view a form from the listing, click on that form s title Patient Not Satisfied And Will Not Return Letter Follow-Up Letter When Patient Does Not Comply With Referral Referral Thank You Letter Thank You Letter To Patient Who Sends Note Of Appreciation Apology Letter Patient Kept Waiting Patient Re-Call Letter Confirmation That Patient s Symptoms Are Being Addressed Collection Letter version one Collection Letter version two Collection Letter version three Letter Writing Off Debt Notice Of Associate Leaving Introduction Of New Associate Letter Notice Of Sale/Retirement And Introduction Of New Doctor Notice Of Office Closing Letter Of Condolence To Patient Seriously Injured During Treatment MAIN MENU RETURN TO TABLE OF CONTENTS

18 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS PROFESSIONAL CORRESPONDENCE To view a form from the listing, click on that form s title Confirmation Of Telephone Call To Lawyer s Secretary Pre-Deposition Letter To Patient s Lawyer Pre-Trial Letter To Patient s Lawyer Transmittal Letter Accompanying Letter Of Protection Letter Of Protection Irrevocable To Attorney To Pay Doctor Letter To Attorney Who Fails To Honor Lein Letter To Lawyer Seeking Status Report Of Malpractice Claim Team Physician Role Limitation Letter Referral Letter To M.D. MAIN MENU RETURN TO TABLE OF CONTENTS

19 CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS REFERENCES To view a form from the listing, click on that form s title Assessment And Outcome Instruments and References Medicare 2000 New Information Medicare Regional Offices MAIN MENU RETURN TO TABLE OF CONTENTS

20 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z MAIN MENU CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those forms To view a form from the listing Click on that form s title A Abuse Report Activities Of Daily Living Causing Problems Activities Of Daily Living Which HelpThe Patient Adjustment Log Advice Failure To Follow Advice Failure To Follow Parent Of Minor Child Advice Failure To Follow Warning Letter Prior To Withdrawal Advice Failure To Follow X-rays Advice Symptom List, Letter Apology Patient Kept Waiting Appointment Work/School Excuse When Keeping Dr s Assessment References Assignment Of Benefits Associate Introduction To Patients Associate Notice Of Leaving Athletic Examination Attorney Ignores Letter Of Protection, Letter To Attorney To Pay Doctor Attorney Letter Of Protection Attorney Pre-deposition Letter Attorney Pre-trial Letter Attorney Request For Records, Responding To Attorney Secretary Letter Authorization Patient Name In Newsletter Or On Bulletin Board Authorization Release Information And Medical Records Auto Accident Exam Form Authors Note

21 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title B Bill Delinquent, Demand Letter Bill Forgiveness Bulletin Board Consent To Use Patient Name On MAIN MENU

22 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z MAIN MENU CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title C Case History Form Checklist Exercise Checklist Patient History Checklist Home Care Checklist Independent Contractors Checklist Interview Checklist Managed Care Checklist Checklist Protection Strategy Checklist Report Writing Checklist Retirement Checklist Risk Management Child Abuse / Neglect Report Child Consent To Treatment Child Parent s Failure To Follow Advice Clinical Lab Request Slip Collection Letter Final Collection Letter Friendly Collection Letter Intermediate Confidentiality Employee Statement Confidentiality Fax Transmissions Confirmation Patient Discontinued Care Voluntarily Confirmation Doctor s Discharge By Telephone Consent Bulletin Board, Name On Consent Informed Consent Observers Consent Minor s Consent Photographs Consent Research Consent Video Consent X-ray Credit Card Payment

23 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title D Daily Notes Narrative Style Daily Notes Alternative Style Daily Notes Alternative Style #2 Depreciation Equipment Log Deposition Attorney Letter, Before Disability Certificate Dissatisfied Patient Letter To Discharge Doctor, Letter Confirming Doctor s Request For Records From Previous Doctor MAIN MENU

24 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title E Employee Confidentiality Statement Employee Independent Contractor, Differences Employment Interview Checklist Employment Physical Examination Employment Physical Examination IME Equipment Replacement Log Examination Athletics Examination General Examination IME Examination Pre-employment Exercise Monitor Exercise Proficiency Test F Fax Transmission Cover Sheet Financial Hardship Payment Agreement Forgiveness Of Bill MAIN MENU

25 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title G-H Hazard Warning History General Health History Red Flag Questions History Social Home Care Checklist Home Care Report MAIN MENU

26 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title I IME Patient Report IME Report of Independent Examination Independent Contractors Checklist Informed Consent Insurance Assignment Insurance Intake Information Insurance Paper Review, Letter To Company After Insurance Rejection Or Reduction, Letter To Patient After Intake General Intake Examination Athletics Intake Examination IME Intake Examination Pre-employment Interview Checklist... Substitute Or Associate Doctor Interview Guidelines, Employees Introduction New Associate Irrevocable To Attorney To Pay Doctor MAIN MENU

27 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title J-K Job Applicant Interview Checklist Job Applicant Interview Guidelines Job Description Patient s MAIN MENU

28 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title L Laboratory Request Slip Locum Tenens (Back-up Doctor) Lawyer, See Attorney Lawyer s Secretary Confirmation Of Telephone Call Legend For Physical Examination Form Letter Of Protection To Attorney Fails To Honor Lien Letter Of Protection Sample Letter Of Protection Transmittal Letter Of Protection Lien Form MAIN MENU

29 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z MAIN MENU CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title M Managed Care Back-Up Doctor Managed Care Contracting Checklist Managed Care Patient Information Managed Care Compliance Letter Withdrawal from Network Managed Care Compliance Letter Reimbursement Not Covered By Contract Malpractice Avoidance Checklist Malpractice Status Report, Letter To Lawyer Seeking Manipulation Record M.D. Referral Letter To Medicare Patient Explanation Medicare Regional Offices Medicare Supplemental Carrier Letter Medicare 2000, New Information Mercy Document Disclaimer Minor Child Abuse Report Minor Consent To Treatment Minor Parent Failure To Follow Advice, Letter MRI Request Form

30 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title N Narrative Reports NCMIC Group Disclaimers Neglect, Child, Report New Problem Evaluation Form Newsletter Consent To Use Patient s Name Noncompliance Parent Of Minor Child Noncompliance Pre-withdrawal Letter Noncompliance Referral, Failure To Schedule Appointment Noncompliance Withdrawal Letter Notice Associate Leaving Notice Office Closing Notice Sale/Retirement And Introduction Of New Doctor O Observer Patient Consent To Outcome Assessment Instruments MAIN MENU

31 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z MAIN MENU CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title P-Q Paper Review By Insurer Patient Letter Following Paper Review By Insurer Protest To Insurer Patient Satisfaction Survey Patient Declining To Accept Patient Discontinuing Care Confirmation When Patient Picked Up Records Patient Dissatisfied, Letter To Patient Injured During Treatment, Letter To Patient Job Description Patient Kept Waiting, Apology Letter Patient Information Required For Chart Patient Re-call Letter Patient Request For Records From Previous Doctor Patient Request For Records, Responding To Patient Research, Consent To Patient Sign-in Sheet Payment Agreement Personal Injury Information (Auto) Photographs, Consent To Physical Education Excuse Physical Examination Form P/I Cases Pre-deposition Letter To Lawyer P/I Cases Pre-trial Letter To Lawyer Pre-deposition Letter to Lawyer Pre-employment Examination Release Form Pre-trial Letter To Lawyer Pregnancy Warning And Consent To X-ray Progress Report

32 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z MAIN MENU CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title R Re-call Letter Records Request Response Authorization Missing Records Request Doctor Asking From Previous Doctor Records Request Letter Responding To Doctor Records Request Letter Responding To Lawyer Records Request Letter Responding To Patient Records Request Patient s Request To Previous Doctor Records Request Release Authorization Records Request Retention Of Referral M.D. Referral Thank-you To Patient Making Release Of All Claims Release Of Records Replacement Log, Equipment Report Child Abuse Report Narrative, Checklist Research Patient s Consent To Participate Response Attorney s Request For Records Response Doctor s Request For Records When No Patient Authorization Response Patient s Letter Of Appreciation Response Patient s Refusal To Allow X-rays Response Patient s Request For Records Retirement Checklist Retirement Notice To Patients Risk Management Checklist Rules of Record keeping

33 A B C D E-F G-H I J-K L M N-O P-Q CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title S Sale Of Practice Notice School Excuse Appointment With Doctor School Excuse Physical Education Seat Belts Mandatory Use Exemption Secretary Lawyer s Letter To Self Help Activities S.O.A.P. Notes Narrative Style S.O.A.P. Notes Alternative Style S.O.A.P. Notes Alternative Style #2 Social History Sign-in Sheet Survey Patient Satisfaction Symptom List R S T U-V W X-Y-Z MAIN MENU

34 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title T Table Of Contents Team Physician Role Limitation Telephone Log Trial Letter To Attorney, Before MAIN MENU

35 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title U Ultrasound Cerebrovascular Request V Video Patient Consent To Visual Analog Scale MAIN MENU

36 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title W Warning Labels Warning Physical Limitations Warning Pregnancy Warning Withdrawal, Prior To Warning X-ray Withdrawal As Doctor Letter Withdrawal As Doctor Warning Prior To Work Excuse Disability Work Excuse Doctor s Appointment Work Job Description Form Workers Compensation Authorization Workers Compensation Exam Form Writing Off Debt MAIN MENU

37 A B C D E-F G-H I J-K L M N-O P-Q R S T U-V W X-Y-Z CHIROPRACTIC FORMS AND LETTERS ALPHABETICAL INDEX Click on a letter of the alphabet to view a listing of those titles To view a form from the listing Click on that form s title X-Y-Z X-ray Consent To X-ray Interpretation X-ray Request Slip X-ray Patient Refusal X-ray Pregnancy Warning And Consent X-ray Refusal To Allow MAIN MENU

38 CHIROPRACTIC FORMS AND LETTERS CUSTOMIZABLE FORMS DOWNLOADING FORMS IN A MICROSOFT WORD FORMAT Besides the samples, you have the option to download BLANK copies of each form or letter in a Microsoft Word document format. This option will allow you to customize each form or letter for your practice needs. Choose the button on any sample form to download that form to your computer. PERSONALIZE THE FORMS WITH YOUR LOGO & PRACTICE INFORMATION Not only can you make changes to the forms, but you can insert your logo and practice information (address, phone number, etc.). Click on the button below for easy-to-follow instructions. PERSONALIZATION INSTRUCTIONS FOR YOUR PROTECTION: Using a form that asks inappropriate questions or that contains information not pertinant to your practice can be damaging if those records were ever reviewed during a malpractice claim. To protect yourself and your reputation, make full use of these customizable forms that can be adapted for your specific use. MAIN MENU

39 Page 1 of 3 ACKNOWLEDGEMENT This is a derivative work. It is with grateful appreciation to the authors of The Chiropractic Form and Sample Letter Book, that this work was possible. Without their kind permission to draw extensively from their original efforts in that project, this revision, designed to fill in the gaps that passage of time always creates in practical response to an evolving industry such as health care, would not have been possible. Copyright 2001, NCMIC Group, Inc., West Des Moines, IA Previous copyright All rights reserved. NCMIC Group Limited License for Publication prohibits the photocopying of this complimentary copy by the recipient for resale or use by anyone other than the original recipient of this text. The sample forms and letters may be copied, altered, substituted, changed, modified and/or revised. for use by the recipient in conjunction with his or her private practice of chiropractic. For information or questions, contact NCMIC Group, Inc., th Street, Suite 102, West Des Moines, IA or-call ed in the United States of America

40 Page 2 of 3 COMPLIMENTS OF NCMIC GROUP, INC. As part of your attendance and participation in the Business Management Seminar presented by NCMIC Group, Inc., you are receiving a copy of this book, The Chiropractic Forms & Letter Book for new practitioners. The book comes to you compliments of NCMIC Group, Inc., the parent company of NCMIC Insurance Company, the nation s leading provider of chiropractic malpractice coverage, today insuring nearly one-half of all practicing doctors of chiropractic. This gift is simply another embodiment of our total dedication to the chiropractic profession: We take care of our own. Best wishes for your future success as you progress in your career as a concerned doctor of chiropractic. NCMIC INSURANCE COMPANY NCMIC leads the field of chiropractic malpractice insurance. The company is a licensed carrier meeting or exceeding stringent state licensing regulations in all 50 states and the District of Columbia. NCMIC provides coverage for more than 26,000 chiropractors. NCMIC has earned an A (Excellent) rating from A.M. Best Company for financial stability, and an A+ rating for strong financial security from Standard & Poor s. This robust financial condition enables NCMIC to meet the twin challenges of growth and diversification, translating into more and better services and products. In addition to funding scientific and clinical research and providing scholarships for students of chiropractic, NCMIC offers Business Management Seminars, Legal Defense Counsel Seminars, Risk Management Seminars and other forums to help advance the profession and its members NCMIC FINANCE CORPORATION NCMIC Finance Corporation (NFC) offers chiropractors the financial tools they need to successfully manage the business side of the practice. NFC works closely with doctors of chiropractic to find solutions to their borrowing needs. For example, NFC finances X-ray machines, chiropractic adjusting tables as well as other office equipment. Flexible payment schedules, low interest rates and no prepayment penalties are benefits of working with NFC. Other NFC business tools: The NCMIC Visa Card that earns Magic Miles travel rewards with no blackout periods a VISA Business Line of Credit long-term disability protection business owners insurance give the practitioner flexibility in meeting financial needs

41 Page 3 of 3 TRIAD HEALTHCARE, INC. TRIAD Healthcare, Inc., offers doctors of chiropractic ready access to efficient network of HMOs, PPOs and other managed care organizations. TRIAD is helping make chiropractic care more accessible to an expanding segment of the population by developing national contracts in such lucrative markets as health insurance, Workers Compensation, auto liability, Medicare/ Medicaid, and wellness care. TRIAD not only benefits health care consumers, it aids the chiropractic professional as well. D.C.s participating in the TRIAD network are able to expand their patient volume and grow their practices by providing professional services to covered plan members. TRIAD brings to managed care a ready-made roster of practitioners who meet rigorous credentialing standards and deliver cost-effective, outcomes-oriented care NCMIC NFC TRIAD Healthcare just three of the many ways we take care of our own. NCMIC DISCLAIMER This book contains neither legal nor accounting advice. The purpose of this book is to assist the doctor, his or her lawyer and other advisors in the formulation of a comprehensive and wellconceived set of forms and letters, professionally reviewed and tailored to the reader s practice. It is a compendium of a variety of forms and letters that could be used, but certainly good practice does not dictate the use of them all. The goal is to provide a broad assortment from which the practitioner can pick and choose the forms and letters that will assist him or her in the clinical management of his or her patients and the risk management of his or her practice. The forms and samples contained herein have been developed from sources believed to be generally appropriate for use by doctors of chiropractic. However, because of variances in state statutes, educational philosophy, professional protocol and preference, NCMIC Group, Inc., assumes no responsibility as to the appropriateness for individual use or comprehensiveness for individual scope of practice offered in a particular form or sample letter. Legal counsel should be consulted for optimal guidance.

42 Page 1 of 2 AUTHORS NOTE STYLE/GENDER The author of any modern, non-fiction work is confronted with difficult choices: (1) He may employ a style that observes strict sexual neutrality, employing such phrases as him or her, his or hers and he or she. (2) He may alternate male and female pronouns, employing one then the other throughout the text. (3) He may arbitrarily and uniformly employ one set of pronouns throughout. The first option is cumbersome, tedious and disruptive to readability. The second is confusing both to author and reader. The third, though not perfect, is much simpler to read and follow. In this work, the use of the male pronoun has no significance other than the readability and simplicity referenced above. We hope this will offend no one and trust that it will be viewed as an effort to avoid doing so and ultimately to aid the reader. STYLE/PROFESSIONAL DESIGNATIONS A similar risk of offending readers confronts authors of works directed to doctors of chiropractic. Chiropractor, physician, chiropractic physician, doctor, D.C., health-care provider and doctor of chiropractic are all used in this text. We recognize that certain of those designations are forbidden to chiropractors in some jurisdictions and that the term physician is eschewed by some D.C.s as having allopathic connotations. To heighten readability and avoid constant repetition, however, we have chosen to make reference to doctors by using the entire panoply of designations. Our use of the term medical is apt to annoy some. In a work of this magnitude, however, to totally avoid its use would result in strained, artificial and cumbersome language. Our use of the term is in its generic sense unless the context clearly dictates otherwise. Likewise, some practitioners may debate the synonymous of: manipulate/adjust, manipulation/ adjustment and manipulative therapy/chiropractic treatment. Our understanding of the uniqueness of the chiropractic adjustment as opposed to the mobilization maneuvers of D.O.s, M.Ds and P.T.s does not dissuade us from using all combinations to avoid monotony, repetition and reader boredom. SCOPE This book contains neither legal nor accounting advice. The purpose of this book is to assist the doctor, his lawyer and other advisors in the formulation of a comprehensive and well-conceived set of forms and letters, professionally reviewed and tailored to the reader s practice. It is a compendium of a variety of forms and letters which could be used, but certainly good practice does not dictate the use of them all. The goal is to provide a broad assortment from which the practitioner can pick and choose the forms and letters which will assist him in the clinical management of his patients and the risk management of his practice. PracticeMakers subscribes to the following statement from a Declaration of Principles jointly adopted by a Committee of the American Bar Association and a Committee of Publishers: This publication is designed to provide accurate and authoritative information in regard to subject matter covered. The publisher is not, however, engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent licensed person should be sought.

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