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Sample Forms

These sample forms were created to assist podiatric physicians and their office staffs in their risk management efforts such as documenting patient care, communicating with patients, and making office systems more efficient.

These forms can be customized to your office. Please note that the information contained in these documents does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only and is written from a risk management perspective to aid in reducing professional liability exposure. Please review these documents for applicability to your specific practice. You are encouraged to consult with your personal attorney for legal advice, as specific legal requirements may vary from state to state.

Agreement for Transfer Retention of Medical Records

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Authorization to Treat Minor in Absence of Parent

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Bill Write off Approval Letter

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Business Associate Agreement (BAA) Form

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Closing - Retiring Practice

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Consent for Off-Label Drug Use

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Consent for Photographs and Videos

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Consent for Treatment of Patient with PVD and/or Diabetes

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Drug Samples Policy and Procedure

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E-Mail Consent Form

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Enterprise Risk Management Worksheet

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Informed Consent Form

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Leaving a Podiatric Group Practice Letter

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Letter Confirming Patient's Termination of Physician-Patient Relationship

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Loss of Insurance Coverage Letter

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Medical Problem List

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Medical Records Release Form

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Medical Referral Form

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Medication Flowsheet

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Missed Appointment Letter

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