Health Services Forms

Make sure your bills get paid. Have your patients sign this Arizona Patient Consent and Medical Lien Agreement at the time of treatment.

• The patient consents to treatment and authorizes release of all medical information with respect to the patient's claim regarding the accident or injury for which the patient is being treated.
• The patient agrees to be personally liable for paying the medical provider's fees regardless of the outcome of the patient's claim.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien out of those proceeds.
• The patient will notify the medical provider if he/she retains new legal counsel.
• Buy the form once, and it's yours to use as often as you require.
• Intended for use only in the State of Arizona.

AR health care providers, make sure you get paid for your services by having patients sign this Arkansas Medical Consent, Release and Irrevocable Lien form at the time that treatment is provided.

• The patient consents to treatment and authorizes release of all medical information.
• The patient agrees to be personally liable for paying the medical provider's fees and is responsible for making all financial arrangements for payment of the account.
• The patient assigns any Medicare or Medicaid benefits to the medical provider.
• The patient gives the medical provider an irrevocable lien on any settlement or judgment proceeds awarded to the patient and authorizes his/her attorney to satisfy the lien out of those proceeds.
• Available in MS Word format.
• Intended to be used only in the State of Arkansas.

Don't take the risk that your bills for medical services will not be paid. Get your patients to sign this California Patient Fee and Lien Agreement form before you provide treatment.

• The patient agrees to be personally liable for paying the medical provider's fees and is responsible for making all financial arrangements for payment of the account.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien out of those proceeds.
• This is a reusable legal form. Buy it, download it, and it's yours to use as often as you require.
• Available in MS Word format and fully customizable.
• Intended to be used only in the State of California.

Do you need an in-home caregiver to provide assistance for you or a loved one? Use this template Caregiver Service Agreement to hire someone to fulfill that role.

• The Agreement can be used to provide support for an elderly person or for anyone else who requires assisted living services in order to keep living in their own home.
• The caregiver can be anyone, including a family member.
• The contract template lists the typical services that a caregiver would provide. You can delete those services which are not applicable.
• The compensation clause contains two options, one for a set rate (hourly, weekly or monthly) and one for a prepaid lump sum amount.
• The form also includes a list of restrictions and obligations which the caregiver must comply with, such as not interfering with or trying to influence the client's decisions, and not accepting gifts or money except as provided in the Agreement.
• This is a generic legal form that does not make specific references to the laws of any country.
• Easy to use and customize.

Get this Authorization form signed in order to get access to a patient's medical records for purposes of chiropractic treatment.

• The patient's doctor or other medical service provider is directed to release the patient's medical records to the chiropractor so that treatment can begin.
• This is a generic patient authorization form that can be used anywhere.
• You can easily customize the form with your logo, office address and phone number.
• Available in MS Word format.

Chiropractors, obtain a general authorization from a patient with this downloadable Chiropractic Patient Blanket Authorization Form.

• When the patient completes the form, he / she is giving a general 'blanket' direction to any and all medical, paramedical and healthcare service providers.
• The patient authorizes these service providers to release to the chiropractor whatever information they may have on file with respect to injuries the patient has sustained and the treatment or care provided.
• The chiropractor is authorized to use this information for treatment purposes.
• This form is available in MS Word format and can be easily edited and customized to fit your business needs.

Bring an associate into your chiropractic practice with this template Chiropractor Associate Contract. Provisions of the agreement include:

• Facilities and services to be provided by the chiropractic clinic to the associate;
• Number of hours the associate is expected to work;
• Billings and collections procedures;
• Ownership of and responsibility for patient files;
• The associate will have first right of refusal to buy the chiropractic clinic if the owner decides to sell.

The Chiropractor Associate Contract is provided in MS Word format, and is fully editable to fit your exact circumstances.

Claim a lien for medical services to make sure you get paid. Have your patients sign this Colorado Doctor's Lien and Patient Consent at the time that treatment is provided.

• The patient consents to the treatment and authorizes the medical facility to release his/her patient information regarding the accident or injury for which the patient is being treated, for purposes of the injury claim.
• The patient agrees to be personally liable for paying the medical provider's fees regardless of the outcome of the patient's claim.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien out of those proceeds.
• The patient will notify the medical provider if he/she retains new legal counsel.

Don't risk not being paid for your services. Get this Colorado Doctor's Lien and Patient Consent form today.

Chiropractors, have each new patient fill out this Confidential Health Record and Information Sheet prior to receiving chiropractic treatment.

• The 5-page form includes sections for:
  • personal and medical history,
  • job-related injuries,
  • current health condition, and
  • a patient consent form for chiropractic treatment.
• This form is fully editable and reusable. Pay for the form once, and it's yours to use as often as you require.

Use this downloadable template form to gather confidential information from patients of a massage therapy clinic.

• All new patients should fill out the form before beginning therapy.
• Patients provide medical and contact information, as well as specific details of any existing condition for which the patient is receiving massage treatments.
• The form can be easily customized to include your office and practice information, logo, hours, etc.
• This is a reusable business form. Once you purchase it, you can use it as often as you like.
• This Confidential Patient Information Sheet for Massage Therapy form is downloadable, editable and easy to use.

Make sure you get paid for medical services rendered to a patient with this Connecticut Doctor's Lien and Patient Consent form.

• Patients should sign this form before you provide treatment.
• The patient authorizes the facility to release medical information about the injury and treatment, for purposes of the injury claim.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien from those proceeds.
• The patient will be personally liable for paying the health care provider's fees if there is no settlement or if it's insufficient to pay the medical bills.
• The patient will notify the medical provider if he/she retains new legal counsel.

Don't wait for settlement to secure repayment of your bills. Do it now with this Connecticut Doctor’s Lien and Patient Consent Form.

Prepare a business plan for a dentist's office with this fully customizable Dental Office Business Plan template.

• The purpose of the Business Plan is to obtain a start-up loan which will be used to buy equipment and supplies, lease office space, and hire staff for the dental practice.
• The Business Plan includes:
  • A market analysis and marketing strategy for promoting the dental services offered by the dentist's office.
  • A financial model with pro formas.
  • A Confidentiality Agreement to protect your proprietary information, such as financial data.
  • Instructions in each section to help you complete the document.
• Available in MS Word format and totally editable to fit your specific circumstances.

Offer a candidate a house staff position at a hospital in the United States with this Letter of Intent / Employment Offer template.

• The employee must obtain a State medical license or intern and residency license before beginning work.
• The employee must successfully undergo drug and criminal background screening.
• The Medical Center will provide malpractice insurance.
• Health care insurance, life insurance and disability insurance are available through the Center's insurers.
• House staff will be reimbursed for parking fees by means of an annual cash benefit.
• Moonlighting is discouraged but not prohibited. The employee's malpractice insurance does not extend to any outside employment.
• This is a fully editable MS Word document.
• Drafted to be used only in the United States.

Don't be a victim. Read Fighting Back: Every Woman's Guide to Survival and learn how to defend yourself against attackers.

This 66-page self defence guide was written by Helene Crane, a 14-year police force veteran. It will teach you how to stay safe, and practice the author's step-by-step illustrated methods to defend yourself against armed and unarmed attackers:

• Learn how to defend against attacks from the front and from the rear.
• Learn how you can turn everyday objects into defensive weapons.
• Discover ways to deal with the emotional and physical aftermath of an assault.

Fighting Back: Every Woman's Guide to Survival is available in PDF format and can be downloaded to Kindle, Sony Reader or other e-readers.

Secure the payment of your bills for medical services by having your patients sign this Georgia Patient Consent and Medical Lien Agreement before treatment begins.

• The patient authorizes the medical practitioner to release any information about the accident or injury being treated for purposes of the patient's injury claim.
• Notwithstanding any settlement of the claim, the patient is personally responsible for paying the fees.
• The medical provider has an irrevocable lien over any amounts awarded to the patient. The patient's attorney is directed to satisfy the lien out of the settlement funds.
• This is a reusable legal form. Once you've purchased it, you can use it as often as you like.
• The template can be customized for your specific business needs.
• This form is intended for use only in the State of Georgia.

Do you treat patients who have been injured by accident or third parties. Have them sign this Illinois Doctor's Lien and Patient Consent Form at the time of treatment.

• The patient gives his/her consent for the treatment and authorizes the medical practitioner to release any information required to conduct the patient's injury claim.
• Regardless of the outcome of the claim, the patient will be personally liable for paying the medical bills.
• The doctor has an irrevocable lien on any settlement or damages awarded to the patient. The patient's lawyer is instructed to satisfy the lien out of the settlement proceeds.
• The patient must give notice if he/she hires a different attorney.
• Intended for use only in the State of Illinois.

Keep Your Nurses and Health Care Professionals for Life is a downloadable 210-page book by Brian Lee, CSP, based on his popular seminars.

• The book delves into the medical profession and gives tips on how to keep our healthcare professionals in Canada and give life back to the profession.
• Discover the 4 imperatives of how to inspire, retain, motivate and empower patient focused nurses and health care professionals.
• Learn more about significant issues such as staff retention, staff empowerment, continuing education and inter-office relationships.
• Keep Your Nurses and Health Care Professionals for Life is a downloadable e-book which is available in PDF format.

Don't gamble with your patient invoices. Have your patients sign this Massachusetts Doctor's Lien and Patient Consent Form at the time treatment is provided.

• The patient consents to treatment and authorizes the facility to release his/her medical information for purposes of the patient's injury claim.
• The patient will be personally liable for paying the medical provider's fees whether or not the claim is successful and damages are awarded.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien out of those proceeds.

You can use this Massachusetts Doctor's Lien and Patient Consent form over and over again. Download it and customize it for your business.

All information collected by a medical office is confidential. Have all of your staff sign this Employee Pledge of Confidentiality.

• In order to comply with privacy laws, all personnel employed in health services positions must pledge in writing to keep all patient information confidential.
• This form is downloadable, editable and easy to use.
• Customize the form by adding your office's logo, and print off copies to use as a hand-out for new employees and practitioners to sign.
• This free form is available in MS Word format.

Secure the payment of your patient invoices with this Missouri Doctor's Lien and Patient Consent form.

• Patients receiving treatment for third party injuries (including on-the-job accidents) should sign this agreement before treatment begins.
• The patient consents to the treatment and authorizes the release of his/her medical information as required to document the patient's injury claim.
• The patient gives the doctor an irrevocable lien on any settlement or damages awarded, which will then be used to pay the lien.
• The patient agrees to be legally liable for paying the full amount of the health care provider's fees, regardless of the outcome of the claim.

Stop worrying over whether your bills will get paid. Get the Missouri Doctor's Lien and Patient Consent form today.

This New York Patient Consent and Doctor's Lien form can ensure that your fees for medical services are paid by placing a lien on damages awarded in an injury claim.

• Patients receiving treatment for third party injuries (including on-the-job accidents) should sign this agreement before treatment begins.
• The legal action may necessitate access to the patient's medical records. The form includes a section where the patient authorizes the hospital to release that information.
• The patient gives the doctor an irrevocable lien on any settlement or damages awarded, which will then be used to pay the lien.
• The patient agrees to be legally liable for paying the full amount of the health care provider's fees, regardless of the outcome of the claim.
• This is a downloadable legal form in MS Word format.
• Intended for use only in the State of New York.

Oregon health care providers, protect your lien rights and make sure your fees get paid with this Medical Services Lien form.

• The lien is claimed by a hospital, clinic, physician or other service provider for any unpaid amount for hospitalization or medical services rendered to a patient, and is claimed against the proceeds of any claim for compensation or damages made by the patient.
• The form includes a copy of ORS 87.565, which explains how the lien form must be filed and served.
• Buy the form once, and it's yours to use as often as you require.
• Available in MS Word format.
• Intended to be used only in the State of Oregon.

Get the consent of a parent for a doctor to perform necessary surgery on a child with this medical authorization form.

• The parent acknowledges having been made aware of the risks involved with the surgery.
• The parent also acknowledges that the surgeon cannot guarantee the operation will be a success.
• The parent consents to the surgery and the use of anesthetic.
• If appropriate (according to age), the minor child also signs the form.
• This is a generic legal form which is not specific to any country.

Set up a program of identity theft protection and detection policies and procedures for a US health care service provider with this Red Flags Rule Policy for Medical Practice.

The Policy is made in accordance with FTC regulations, and covers:

• the types of information that will be included under the Policy,
• types of red flag events, i.e. situations which should raise suspicion of potential identity theft, and procedures for detecting red flags,
• appropriate responses to red flags,
• staff training and program updates,
• compliance by service providers (business associates).

Reduce the risk of identity theft in your facility. Download the USA Red Flags Rule Policy for Medical Practice today.

Chiropractors can refer a patient to a doctor with this free Physician Referral Form.

• The Referral Form would be used to refer a chiropractic patient to a new doctor in circumstances where the chiropractor discovers a medical condition that should be treated by a physician.
• The form has sections for pertinent findings and recommendations.
• This form can be filled in on the computer or device, or used as a pre-printed form to be filled in by hand.
• Available in MS Word format.

Prepare a release form for signing by a client who receives counselling services from a psychologist or other practitioner with this Release of Liability and Waiver of Claims form for Canada.

• The form can be used for adults or for a parent or guardian signing on behalf of a minor.
• The client waives the right to sue or claim compensation for any injury, illness, damage, disability or death arising out of the client's involvement in the services or activities provided by the practitioner, and releases both the practitioner and the owner of the business premises in which the counselling services are located.
• The client further covenants not to sue the released parties.
• The client also indemnifies and holds the premises owner harmless against any losses or claims.
• The form is available as a downloadable and fully editable MS Word template.
• Intended to be used only in Canada. This form may not be usable in Quebec.

If you provide COVID tests to minor children, protect yourself from claims with this Release of Liability form for Canadian test providers.

• The parent of the child acknowledges they are aware of the contagious nature of the disease and the risks of exposure from the child attending on the test provider's premises for purposes of the test.
• The parent acknowledges that the test provider does not guarantee the validity of the test and that a negative result could be a false negative.
• The parent accepts sole responsibility for checking and complying with the requirements of any particular airline or country of destination, if the test is for purposes of international travel.
• The parent agrees that a positive test result will be shared with the appropriate health authorities.
• The parent will indemnify and hold the test provider and its employees and stakeholders harmless against any costs or expenses, and releases the test provider from any liability or claim for damages for illness, injury, disability, death or property damage.
• The parent will ensure that the child and the family members comply with all federal, provincial and local laws, orders and guidelines to stop the spread of COVID-19, including those involving travel
• This is a Canadian legal template which can be used in any province or territory, except for Quebec where a French language version may be required to comply with provincial laws.

If you run a testing facility for COVID-19, protect yourself from claims with this Release of Liability form for Canadian test providers.

• The patient acknowledges they are aware of the contagious nature of the disease and the risks of exposure from attending on the test provider's premises for purposes of the test.
• The patient acknowledges that the test provider does not guarantee the validity of the test and that a negative result could be a false negative.
• The patient accepts sole responsibility for checking and complying with the requirements of any particular airline or country of destination, if the test is for purposes of international travel.
• The patient agrees that positive test results will be shared with the appropriate health authorities.
• The patient will indemnify and hold the test provider and its employees and stakeholders harmless against any costs or expenses, and releases the test provider from any liability or claim for damages for illness, injury, disability, death or property damage.
• If a re-test is required due to inconclusive or false results, the test provider will cover the costs.
• This is a Canadian legal template which can be used in any province or territory, except for Quebec where a French language version may be required to comply with provincial laws.

Report student injury or abuse to the authorities with this free downloadable template Report Form.

• The form should be completed and filed as soon as possible if the child is injured on school property or if the child has suffered any kind of abuse by a school employee or other person on school property.
• The Report must be filled out by a parent, guardian or concerned adult, who should then notify the proper authorities, such as the police and child welfare agencies.
• The form can be completed on a computer or used as a pre-printed form to be filled in by hand.
• Available in MS Word format.
• This form can be used anywhere that does not have a statutory form prescribed by law.

Prepare a Resume for Health Care Professional with this easy-to-use template.

• professional experience,
• education,
• clinical affiliations,
• memberships,
• community involvement,
• competencies ⁄ proficiencies,
• references.

Prepare a Residential Care Agreement for patients of a care facility in Scotland with this ready-made template form.

• This Agreement can be used for either short term or long term care.
• The fees paid by the patient (resident) will be based on a financial assessment carried out in accordance with the National Assistance (Assessment of Resources) Regulations 1992.
• If the resident has to temporarily live away from the care facility, the caregiver will keep the accommodation available for the resident and reduce the fee payable.
• The resident, his/her family and the caregiver will develop a plan of care which will be reviewed regularly to ensure that it continues to meet the resident's needs.
• The caregiver will provide accommodation, food, laundry, social care services, and comforts, and maintain the standard of care required by the Regulation of Care (Scotland) Act 2001. The resident is responsible for providing his/her clothing, toiletries and personal items.
• The caregiver will maintain a safe and healthy environment for residents, and will ensure that procedures are in place to manage dispensing of medication.
• Available in MS Word format and fully customisable to fit your particular circumstances.
• Intended to be used only within Scotland.

You have a right to get paid for medical services rendered. Get patients to sign this Tennessee Patient Consent and Doctor's Lien when providing treatment for third party injuries.

• The patient consents to the release of his/her medical information to support the patient's personal injury claim.
• The patient will be liable for paying the full amount of the medical provider's fees, whether or not the claim is successful.
• The medical service provider has an irrevocable lien on any settlement or damages awarded to the patient and the patient's attorney is instructed to satisfy the lien out of those proceeds.
• The patient will notify the medical provider if he/she retains new legal counsel.

The Tennessee Patient Consent and Doctor's Lien form will ensure that your bills are paid. Download it today.

Secure payment of your medical fees by getting your patients to sign this Texas Patient Consent and Doctor's Lien Agreement before treatment begins.

• The patient authorizes the doctor / hospital to release any information about his/her injury and treatment for purposes of the personal injury claim.
• Regardless of the outcome of the injury claim, the patient is personally responsible for paying the fees.
• The medical provider has an irrevocable lien over any amounts awarded to the patient. The patient's attorney is directed to satisfy the lien out of the settlement funds.
• This is a reusable legal form. Once you've purchased it, you can use it as often as you like.
• The template can be customized for your specific business needs.
• Intended for use only in the State of Texas.

Rent space in a wellness facility to a therapist for treatment, consultation and therapy purposes with this easy-to-use rental contract form.

• The contract can be used for monthly or weekly rentals.
• The rental fee covers use of the treatment room for sessions during regular business hours. After hours appointments must be pre-approved and will be charged out at an additional rate.
• The wellness facility will provide reception service, client parking, use of washrooms and common areas, and other services.
• The therapist must provide proof of professional certification and evidence of liability insurance coverage.
• The contract template includes provisions for advertising by the therapist on the facility's website and social media pages.
• This is a generic agreement form that can be used in most jurisdictions.
• Buy and download the template, customize it for your business and use it as often as you need to.

Do you provide home care workers for assisted living clients in the USA? Write up your client contracts quickly and easily with this Home Care Provider Agreement.

• The caregiver will work for the client on the days and at the times that the parties agree to.
• The caregiver will provide services such as cooking, bathing, driving and other duties that the client cannot perform for him/herself.
• Provisions for termination of the agreement before and after a specified probationary period.
• The caregiver agrees to keep record of any accidents and to report to the company.
• Any party in breach of the agreement shall pay reasonable attorney's fees or costs incurred by the other party.

Don't leave the hospital open to additional claims when settling a claim from a patient. Get the patient to sign this Release of Damages Claim as a condition of the settlement.

• The Release form is for medical damages claims in the United States.
• The patient releases the hospital from its present claim and from any future claims for damages, costs, expenses or compensation with respect to treatment the patient received in the hospital.
• The release is documentary evidence of full and complete settlement of the claim, and is intended to avoid litigation.
• This is a reusable legal form. When you purchase it, you can download it, save it, print it, use it as often as you like.

Protect yourself and your massage business against claims for injury or damages with this Waiver for Massage Therapy form.

• Get your patients to sign the Waiver form before you provide services.
• The patient acknowledges the risks inherent to the procedure, and states that his/her participation in the massage session is voluntary.
• The patient assumes all risk associated with the massage therapy.
• The patient releases the clinic and the therapist from any liability.
• Available in MS Word format. Easy to customize, re-usable.

This ready-made set of Website Terms of Use are created especially for fitness businesses that offer online workouts, exercise and diet plans, and health and wellness products.

• These Terms of Use can be used for online fitness services that are available to users in the United States and Canada. The template includes provisions covering:
  • memberships, orders, shipping, pricing and taxes;
  • privacy, collection of personal information;
  • prohibited use of the website;
  • disclaimer of warranties;
  • content submitted by users;
  • disclaimer of medical and professional advice;
  • assumption of risk and participation waiver;
  • indemnification and release, limitation of liability;
  • dispute resolution by arbitration;
  • buyer's right to cancel provisions, under Canadian laws.
• The Terms of Use template comes in MS Word format and is easy to edit to fit your exact needs.
• The file can be easily converted to formats for online use, such as HTML.

Make sure your fees for medical services get paid. Have your patients sign this Wisconsin Doctor's Lien and Patient Release.

• You can claim a lien for the fees for medical services provided to a patient with respect to accidents or injuries caused by third parties (including injuries sustained on the job).
• The patient must give his/her consent for the release of any medical information required for purposes of the patient's injury claim.
• The medical practitioner has an irrevocable lien on any settlement or damages awarded. The amount of the lien will be paid from any damages or settlement amounts paid to the patient.
• Regardless of whether or not the patient's injury claim is successful, the patient remains legally liable for paying the full amount of the fees.

Don't risk not getting paid. Download this Wisconsin Doctor's Lien and Patient Release Form for your facility.

WY health care providers, preserve your lien rights for medical services rendered with this Wyoming Patient Consent and Doctor's Lien form.

• The patient consents to treatment and authorizes release of all medical information with respect to the patient's claim regarding the accident or injury for which the patient is being treated.
• The patient agrees to be personally liable for paying the medical provider's fees regardless of the outcome of the patient's claim.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien out of those proceeds.
• The patient will notify the medical provider if he/she retains new legal counsel.

Don't risk not getting paid. Download the Wyoming Patient Consent and Doctor's Lien form for your billing office.