Which Forms to Use When & Where

Hey guys!

I put together this post as a reference for which forms you need for which patients, and what they are/how to make them.

Please review any forms you make yourself or purchase from myself or another company with your lawyer and/or malpractice insurance company so you can make sure they fit with your individual scope of practice laws.

These forms are essential to your practice:

New Patient Intake: Pretty self explanatory, this form collects your patient’s basic information (full name, address, email, phone) as well as their insurance information and a thorough health history of current and past symptoms. I arrange mine by systems (cardiovascular, digestive, etc.) so I can easily scan which systems/TCM organs the patient is having issues with.

Informed Consent for Acupuncture: Required by nearly all malpractice carriers, this form lets your patient know the risks and side effects of a typical acupuncture/TCM treatment (bruising, slight bleeding, soreness, etc.), and has a place for them to acknowledge and sign.

Notice of Privacy Policies: This form explains to your patient that their health information is confidential except in specific situations, explains that they have a right to their information and how they can obtain it, and has a place for them to acknowledge and sign. Should be HIPAA compliant.

Financial Hardship Agreement for Cash Patients: If you take cash-paying patients and you bill insurance, this is a form that’s essentially required by law for all cash-paying patients to sign. It acknowledges that because they are paying cash, your rates are lower than your “full-fee” of what you typically charge insurance companies. It has a place for you to write in you agreed upon “cash” amount, and a place for your patient to sign.

Insurance Authorization and Billing: This is a form that is necessary for all patients whom you are billing their insurance. It’s essentially just a consent from your patient that you can bill their insurance on their behalf.

Minor Release Form: For any patient who is under the age of 18. It’s essentially an informed consent for treatment that the patient’s parent must sign.

Standard SOAP: The basic SOAP-style form to be used at every treatment. This keeps track of symptom progression, a basic exam, exactly what treatments you used + points needled during the treatment.

Statement of Account: This is great for your patient’s file folder. It’s a record of each treatment, and is incredibly useful for insurance patients. Ideally, it should have sections for the date of their treatment, what they owe (from acupuncture as well as herbs/other), what they paid, whether you charged their insurance or not, what you were reimbursed from their insurance, what you owe back to them, and/or what they owe to you.

Superbill & Telemedicine Superbill: I’m listing these as essential because sooner or later you’ll probably come across a patient that wants one. A superbill is essentially an itemized receipt of a patient’s treatment (why you did during the treatment and how much it cost). It should have place for ICD codes as well as CPT codes. Your patient can submit it to their insurance company if they choose (to seek reimbursement or to pay their deductible), or they may use it for their own records.

Not essential, but useful:

Payment Plan Contract: I may be the original inventor of this, but it’s so great to see other acupuncturists using their own version (or my version) in their practices. It’s incredibly easy to implement, and it formulates a steady income (very useful if you are just starting out)! Basically, to create this, you’ll just need to have in writing an agreed upon rate that you charge your patient’s card at the same time every month, so they are able to pay off their initial course of treatment. It should also have a place that says you will send them an invoice every month, letting them know the remaining balance. Mine has an option for the invoice to either be “mailed” or “emailed.” For cash-paying patients, this is like a health credit card with a 0% interest rate. I set my pay-off rate as no less than $149/month.

Supplemental SOAP For Pain: Useful for monitoring specific conditions, this is a space for all the extra notes that won’t fit on a standard SOAP form if you are treating pain. Ideally, it monitors a simple “1-10” scale for any certain condition/pain, quality, frequency, stress capacity, rebound capacity, and medication levels.

Insurance Verification Form: This is an important form for if you’re doing your own insurance billing. For when you are calling their insurance company, this form should have a space to list what your patient’s benefits are, what their deductible is, how many visits are allowed per year, and if there are any diagnosis requirements (ICD10 codes).

Record of Items Subject to Sales Tax: This is an easy way to keep track of sales tax for herbs/other items you are selling in your office at retail. It should have a space for the date and the total sale (of herbs/other), and kept in a general clinic folder/binder used for keeping track of income/expenses. Then, for easy accounting, it can include a simple math equation on how to figure out how much of the sale was tax, and how much was for the actual product. See below for an easy equation on how to do this.

Combined totals for entire year or filing period divided by (1+tax percentage in your county) = amount you file as income subject to sales tax. (example for a total of $ 53.82 with a 7.75% tax rate included): $ 53.82 / 1.0775 = $ 49.95. 

$49.95 is product sale. The rest ($ 3.87) is sales tax collected that you owe the state.

Free Consultation: A script for a free consultation appointment in person or over the phone. I’ve had incredible success with free consultations in my business, and I think they are a valuable resource for anyone trying to attract new clients. Focus on building rapport with the patient, asking what their health complaints and goals are, and what a typical wellness plan would look like if they were to come to you for treatment.

This is when you would use these:

Just getting in the door:
Free Consultation

First-time patient paying cash (have them fill out and sign):
New Patient Information
Informed Consent for Acupuncture
Notice of Privacy Policies
Financial Hardship Agreement for Cash Patients
Optional: Minor Release Form
Optional: Payment Plan Contract
Optional: Superbill (if patient is submitting treatments to their insurance themselves)

First-time patient for whom you are billing their insurance (have them fill out and sign):
New Patient Information
Informed Consent for Acupuncture
Notice of Privacy Policies
Insurance Authorization and Billing
Optional: Minor Release Form

Disclaimer: I am an acupuncturist in California, and although this is what I do, please check with your insurance biller and your malpractice/liability insurance carrier to know which forms are essential for them and for your patients.

That’s it! That’s what I use!

If you want to make your own, hopefully this post sheds some light on what you’ll need and how to make them. If you want to get mine (and customize them yourself), click here: