In this post I want to cover the topic of forms, tips for creating ones for your private practice, and how to keep it all HIPAA compliant!
When I first started my practice I spent TONS of time getting the initial paperwork and handouts all in line. I was clueless on what I actually needed on these forms and how to go about making them “official” in my office.
I hope that after reading today’s blog post you have a few ideas and a great direction on how to create yours, or by-pass, the headaches completely.
What forms do you really need?
- Client registration form – this is the first one to really spend time building. On this form, you collect all the basic information about your client: name, gender, occupation, address, and contact information. I want you to also ask how they heard about you or who referred them. This will allow you to reach out to those people and provide you more ideas about your marketing. If you are taking insurance you will also want to collect all that information on this sheet too.
- Office Policy/Cancellation Policy – this form needs to state clearly your policies in order to set clear boundaries with clients and have expectations up from. Also, with your cancellation policy make sure it is very black and white and has a place that patients acknowledge they read this form and sign it.
- Intake Form/ Health History/ Patient Questionnaire – this form can be really helpful to get back before you see your client so you can have a chance to plan and prep before they get there. Sadly, getting forms back before someone comes in is rare, especially if you have paper forms.
As you build this see what else is out there. Next time you go to your doctor’s office, massage therapist, chiropractor, etc. see what they have you fill out.
Types of information you might want to include
- What brings you in today?
- What are you struggling with currently?
- Have you experienced a recent change in appetite, weight, etc?
- What medications do you currently take?
- Please list (check off) all your current medical and psychological diagnosis.
- List off your food allegories or intolerance.
- Are you physically active? If so, please tell me about it.
- Please write out what you ate and drank yesterday.
- Consent to Care/ Consent to Treat – this form is giving you, the dietitian permission to treat the patient and that if something goes wrong they will not hold you liable. I call this form the CYA (Cover Your A@&) form. The top portion of the form needs to say what you will do in your sessions and then at the bottom have the client agree to the form.
- Medical Record Release of Information – this form allows you to talk to other health care providers. You might be thinking what’s the purpose of this, and this price of paper is magical for marketing later on along with coordination care and doing your job as a dietitian.
- HIPAA Policy – we all know we need to have this in place. Again, research what is out there and see what other offices have made you sign in the past. You MUST have this form in place.
- Welcome letter
- Directions and map to your office
- What to expect in your initial session
Paper vs. Electronic
Think about when you go to the doctor’s office and you have a book of paper to fill out; it can be annoying because it feels like each form is asking the same stuff. Be mindful in your form creation to see if you can make them neat, clean and not duplicated. There isn’t a standard amount forms you need, and every practice is different.
When I started out and for a long time we had paper forms for when a client comes in. Keep in mind all paper forms MUST be stored in a locked cabinet in order to be HIPAA-Compliant. If you are wanting to go high tech and use Google Forms make sure you are using their Google Business suite to be HIPAA compliant.
If you are feeling a bit freaked out and overwhelmed after reading this entire post… I got your back! My Private Practice Paperwork course has all forms for you to purchase and upload your logo to them.
Adrien Paczosa is a Registered and Licensed Dietitian practicing in Austin, Texas and the surrounding counties.
She is the founder of Fearless Practitioners, the division of her business that offers training to dietitians and wellness professionals and I Live Well Nutrition her Dietitian practice started in 2007. In 2015 Adrien launched Fearless Practitioners to help other Dietitians and Wellness Professionals build and grow their own private practices.