Medical Mutual Insurance Company of Maine

Physician » Risk Management » Forms

Below you’ll find samples of forms developed by Medical Mutual to help clients document important information for patient records.

Form Disclaimer

Appointments

• Missed/Canceled Appointment Stamp
• Missed Appointment Letter - Office Practice
• Missed and Canceled Appointment Tracking Sheet
• Reminder Card

Authorized Signatures

• Log

Chronic Pain Management

• Checklist: Chronic Pain Management Patient Documentation – Initial Assessment
• Checklist: Chronic Pain Management Patient Documentation – Reassessment
• Chronic Pain Management Agreement
  Please see the practice tip entitled: Drug Diversion and the Drug-Seeking Patient
• Chronic Pain Management Agreement (Lower Health Literacy)

Complaints

• Log

Consent/Authorization

• Authorization for Release of Health Care Information
• Authorization for Release of Health Care Information
• Confidentiality Statement
• Consent to Medical/Surgical Office Procedure
• General Consent and Acknowledgment
• General Consent and Acknowledgment
• General Consent to Treatment and Right to Refuse Treatment
• Informed Refusal
• Informed Refusal (Plain English)
• Vaginal Birth after Cesarean Section (VBAC)
  • Consent to Attempt a Trial of Labor
  • Consent to Attempt a Trial of Labor
• Refusal of Screening Examination and Treatment

Diagnostic Tests

• Report Verification Stamp
• Diagnostic Tracking Log

Distribution of Sample Medicine

• Inventory Inspection Log
• Patient Distribution Log
• Patient Instructions
• Refrigerator & Freezer Temperature Log

Documentation

• Creating a Policy for Patient Disclosure of Unanticipated Outcomes
  • Hospital Policy
  • Office Practice Policy
• Documentation of the Discussions following an Unanticipated Outcome
• Template: Disclosure of Unanticipated Outcomes
  • Hospital
  • Office Practice

Fall Prevention

• Post-Fall Event Algorithm

Health Maintenance

• Adult Tracking Log
• Fall Risk Factors

Incident Report

• Incident Report Form

Medical Use of Marijuana

• Certification of Eligibility For Medical Use of Marijuana

Medication – Prescription

• Flow List
• Certification of Eligibility For Medical Use of Marijuana
• Pocket Medication List
• Prescription Record
• Warfarin Dose Reminder Chart and Outpatient Anticoagulation Flowsheet
  Please see the practice tip entitled:Anticoagulation Management in the Physician Office

Narcotics and Controlled Drugs Inventory Record

• Instructions
• Inventory Record

OSHA Regulations

• Standard Eyewash Algorithm

Patient Changing Physicians

• Acknowledgement Letter

Patient Satisfaction

• Sample Survey
• Sample Mini Survey Tool

Physician Office

• Patient Safety Plan
• Table of Contents for Physician Office Policy Manual
• Safety Walk-around Checklist
• Staff Competency Checklist

Problem List

• Chronic & Acute Problems Log

Telephone/Fax

• Message Pads
• Sample Fax Cover Sheet
• Telephone Triage
  • Telephone Triage Algorithm
  • Telephone Triage/Message Form
  • Telephone Triage Program
  • Telephone Triage Quality Review Checklist

Temporary Staffing

• Sample Forms and Policies

Termination of the Physician Patient Relationship Letter

• Termination Policy
• Termination Letter
• Please see the practice tip entitled: Termination of the Physician/Patient Relationship

Therapy

• Therapy Animal Program Policy and Procedure Outline

Unanticipated Outcomes

• Documentation of the Discussions following an Unanticipated Outcome
• Office Practice setting
  • Creating an Office Practice Policy for Patient Disclosure of Unanticipated Outcomes
  • Template: Disclosure of Unanticipated Outcomes
• Hospital setting
  • Creating a Hospital Policy for Patient Disclosure of Unanticipated Outcomes
  • Template: Disclosure of Unanticipated Outcomes

Violence

• BrǾset Violence Checklist