Forms: Quick, helpful, handy risk management tools.
Risk Management » Forms
Below you’ll find samples of forms developed by Medical Mutual to help clients document important information for patient records. If you’d like advice on designing a form to document certain information as part of your practice, call the Risk Management Department at 207.775.6576. Or email us with an outline of your form request.
Appointments
- Appointment
Tracking Log [PDF]
- Missed/Canceled Appointment Stamp
- Missed Appointment Letter - Office Practice [PDF]
- Reminder Card [PDF]
Authorized Signatures
- Log [PDF]
Chronic Pain Management
- Chronic Pain Management Agreement
Please see the practice tip entitled: Drug Diversion and the Drug-Seeking Patient
Complaints
- Log [PDF]
Consent/Authorization
- Authorization for Release of Health Care Information [PDF]
- Confidentiality Statement [PDF]
- Consent to Medical/Surgical Office Procedure [PDF]
- General Consent to Treatment and Right to Refuse Treatment [PDF]
- Vaginal Birth after Cesarean Section (VBAC)
- Refusal of Screening Examination and Treatment [PDF]
Diagnostic Tests
Distribution of Sample Medicine
- Inventory Inspection Log [PDF]
- Patient Distribution Log [PDF]
- Patient Instructions [PDF]
- Refrigerator & Freezer Temperature Log [PDF]
Documentation
- Creating a Policy for Patient Disclosure of Unanticipated Outcomes
- Hospital Policy [PDF]
- Office Practice Policy [PDF]
- Documentation of the Discussions following an Unanticipated Outcome
- Template: Disclosure of Unanticipated Outcomes
- Hospital [PDF]
- Office Practice [PDF]
Health Maintenance
- Adult Tracking Log [PDF]
- Fall Risk Factors [PDF]
Incident Report
- Incident Report Form [PDF]
Medical Use of Marijuana
Medication – Prescription
- Flow List [PDF]
- Certification of Eligibility For Medical Use of Marijuana [PDF]
- Pocket Medication List [PDF]
- Prescription Record [PDF]
- Warfarin Dose Reminder Chart and Outpatient Anticoagulation Flowsheet [PDF]
Please see the practice tip entitled:Anticoagulation Management in the Physician Office
Narcotics and Controlled Drugs Inventory Record
- Instructions
- Inventory Record [PDF]
Patient Changing Physicians
- Acknowledgement Letter [PDF]
Physician Office
Problem List
Unanticipated Outcomes
- Documentation of the Discussions following an Unanticipated Outcome
- Office Practice setting
- Hospital setting
Telephone/Fax
Termination of the Physician Patient Relationship Letter
- Please see the practice tip entitled: Termination of the Physician/Patient Relationship
Therapy