Serving Chiropractors and Their Patients

Forms

A. Wisconsin Regulatory Department

  1. Applications (Exam, New Grad, Endorsement, Nutritional Counseling, Temporary, Re-registration)
  2. License/Preceptorship
  3. Continuing Education
  4. Examination
  5. License Renewal
  6. File a Complaint
  7. Self Reporting a Conviction
  8. Professional Assistance Program
  9. Chiropractic Technicians (CT)
  10. Chiropractic Radiologist (CRT)

B. “Doctors Lien” (Assignment of Benefits)

  1. Assignment of Benefits (“Doctor’s Lien”) by Atty. Dan Riegleman
  2. Notice to Patient’s Attorney/Third Party of Existence of Assignment of Benefits (“Doctor’s Lien”) by Atty. Dan Riegleman
  3. Letter to Patient whose Attorney Refuses to Acknowledge Assignment of Benefits (“Doctor’s Lien”) by Atty. Dan Riegleman
  4. Letter of Protection from Attorney/Third Party by Atty. Dan Riegleman
  5. Notice to Attorney or Third Party About Procedure to be Taken Following Settlement or Verdict with a Patient who Signed Assignment of Benefits Form (“Doctor’s Lien”) by Atty. Dan Riegleman
  6. Notice/Letter Regarding Assignment by Atty. Dan Riegleman

C. Patient Healthcare Records/HIPPA

  1. Authorization for Disclosure of Healthcare Information by Atty. Dan Riegleman
  2. Correspondence Relating to Request for Release of Health Care Information by Atty. Dan Riegleman
  3. Notice of Restrictions on Redisclosure of Health Care Records by Atty. Dan Riegleman
  4. Certification Form to Accompany Requested Health Care Records by Atty. Dan Riegleman
  5. Certification Form to Accompany Requested Health Care Bills by Atty. Dan Riegleman
  6. Doctor’s Notification to Patients of Relocation/Transfer of their File to Another Office or Location by Atty. Dan Riegleman
  7. Acknowledgement of Receipt of HIPAA & Notice of Privacy Practices for Protective Healthcare Information by Atty. Dan Riegleman
  8. INVOICE for Duplication of Healthcare Information by Atty. Dan Riegleman
  9.  Sample Invoice – HITECH Patient Record Duplication by Atty. Dan Riegleman

D. Practices and Procedures

  1. Informed Consent to Chiropractic Treatment by Atty. Dan Riegleman
  2. Patient X-ray Waiver – Release and Indemnification Form by Atty. Dan Riegleman
  3. Office Policies and Procedures for Patients with Personal Injury Claims by Atty. Dan Riegleman
  4. Notice to Patients of Options Available upon Insurance Companies Refusal to Pay a Claim by Atty. Dan Riegleman
  5. Patient’s Release/Indemnification of All Claims And Covenant Not to Sue Doctor by Atty. Dan Riegleman
  6. Payment Plan for Patient with a Balance/High Deductible Coverage by Atty. Dan Riegleman
  7. Financial Hardship Agreement by Atty. Dan Riegleman
  8. Patient’s Voluntary Financial Statement by Atty. Dan Riegleman
  9. Notice to Insurer of Waiver of Patient’s Co-payments/Co-insurance/Deductible Pursuant to Wis. Stats. §446.02(10) by Atty. Dan Riegleman
  10. Patient Consent to Chiropractic Treatment and Financial Agreement on Payment for Services (Non-personal Injury/Worker’s Compensation Patient) by Atty. Dan Riegleman
  11. Authorization and Assignment of Insurance Benefits by Atty. Dan Riegleman
  12. Patient’s Authorization for Bank Payments (“EFT” Debits) by Atty. Dan Riegleman
  13. Notices Required under the Fair Debt Collection Practices Act (FDCPA) by Atty. Dan Riegleman
  14. Patient Assignment of Medical Payments from Auto Insurance by David Michel
  15. Letter to Attorney on Selection of Patient Coverage – Non Medicare Patient by David Michel
  16. Letter to Attorney on Selection of Patient Insurance Coverage – Medicare Patient by David Michel

E. Refusal/Discontinuation of Patient Care

  1. Notice to Patient of Doctor’s Discontinuance/Termination of Chiropractic Treatment by Atty. Dan Riegleman
  2. Notice to Another Physician on Referral of Active Patient Care Pursuant to Wis. Stat. §446.02(7)(d) by Atty. Dan Riegleman

F. Patient Litigation

  1. Request Form to Attorney on Status of a Patient’s Case or Claim by Atty. Dan Riegleman
  2. Doctor’s Letter to Patient’s Attorney Seeking Patient Records or Narrative Report on Required Costs/Prepayment by Atty. Dan Riegleman
  3. Doctor’s Letter to Patient’s Attorney Seeking Deposition or Trial Testimony on Required Costs/Prepayment by Atty. Dan Riegleman
  4. Notice/Letter to Obtain “Medical Payments” Coverage for Patient by Atty. Dan Riegleman
  5. Assignment of Patient’s Legal Interest to Doctor in Order to Pursue Claim/Litigation Against Insurer or Third Party by Atty. Dan Riegleman
  6. Letter to Adjuster for Recovery of Treatment Charges (First Party Health Insurer and Non-Workers Compensation Patient) by Atty. Dan Riegleman
  7. Personal Injury Letter to Adjuster on Recovery of Med Pay/PIP/and other Direct Benefits owed to Patient by Atty. Dan Riegleman

G. Workers Compensation

  1. Workers Compensation – Letter to Adjuster on Recovery for Treatment Charges by Atty. Dan Riegleman
  2. Doctor’s letter to insurer/self-insurer explaining why patient’s treatment was necessary and providing notice of possible submission of dispute to the Department of Workforce Development by Atty. Dan Riegleman
  3. Letter to Worker’s Compensation Insurer following their Request for Reimbursement of Patient’s Billing Payment by Atty. Dan Riegleman

H. Practice Materials Available for Purchase from Contributors

  1. Steven Yeomans, D.C. online store

I. Miscellaneous

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