Health Services Forms

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.