Your practice is up and running, and you’re seeing patients – awesome! But, now it’s onto the paperwork, which can sometimes feels like it’s never ending. In this article, we break down all the important forms required for patient care, and give you tips to streamline the process.
Also, If you’re a member of the Academy, be sure to check out the Eat Right website for more information and sample forms. By the way, Healthie dietitians can use our templates of these forms (a huge time saver for nutrition professionals just starting out).
- Basic information: Collect client information like name and address, phone numbers, emergency contacts, and more.
- Insurance information: If you take insurance, have your clients indicate their insurance info early on in your conversations. That way, you can both be fully informed as to the level services covered, and you’ll have their information on file.
- Nutritional Assessment Form: Collect information like nutritional goals, their reasons for a visit with you, and more. This can be as high level or detailed as you like, as we’ve learned that no two RD intake forms are the same! Some dietitians have their clients fill this out in advance of their first appointment, while others prefer to complete this with their client as a guide to discussion.
- HIPAA Privacy Notice: We know you consider protecting your patients’ health information is of critical importance to you. That’s why we recommend you share a HIPAA Privacy Notice with your patients, which informs patients as to how you protect their information, and assures them that you won’t be sharing their information without their explicit approval.
- PCP Referral Form: Insurance companies will often require that you provide a referral from a primary care physician as part of your treatment. If this is the case, having the client’s PCP complete your referral form can streamline the reimbursement process.
- Information Release Authentication: Working as part of a care team with other health providers? During your initial intake, particularly in medical settings, we recommend having your clients complete an information release form to write down the individuals with whom you can connect with regarding patient information. Typically this includes other doctors, nurses, and behavioral specialists, but in some cases could include a client’s family members or guardians.
- Statement of Financial Responsibility: Whether or not you take insurance, it’s important to ensure you have a way of getting paid for every client. Having a client sign this statement assures that they are responsible for paying for services rendered.
- Cancellation Policy: Ideally, clients always show up on time and never cancel at the last minute. Unfortunately, this just isn’t the case. Establishing a cancellation policy isn’t fun, but for many RDs is important. We’ve seen a whole range of cancellation policies, from those that charge a small fee for cancellations within 24 hours, to those that request the full fee of an appointment. Whatever way you decide, make sure to have this discussion with your client early on in your relationship.
- Superbill: Don’t bill to insurance, or request that your patients submit claims directly to their insurance provider? Prepare a Superbill for your client. We generally recommend preparing it immediately following a client appointment.
- ADIME, SOAP, or Free-Text Charting: Write up your notes during and following a patient visit to come up with a plan for care. ADIME and SOAP charting forms are a part of the RD nutrition care process, and provide an organized format to Assess, Diagnose, Intervene, Monitor, and Evaluate your patients for ongoing care.
- PCP Follow-up form: Did another provider refer a patient, and are they requesting a summary of your visit? Submit a PCP Follow Up form with an overview of your visit. Typically, this is a modified version of your charting, with additional summary information too. Pro-tip: good and timely communication is a great way to build strong relationships with referring providers.
Now, don’t you wish that this paperwork would just go away, patients would complete these forms electronically, and it’d all be stored in one secure place? If only such a platform existed… 😉 But seriously, drop us a line (email@example.com) if you have any questions about forms.