Order Form for Office Forms and Patient-Education Brochures
Risk Management Forms and Sample Letters
Risk Management Manual
Risk Management Patient Materials
Risk Management Specialty Materials
More Useful Risk Management Tools
Order Form for Office Forms and Patient-Education Brochures
Physicians Insurance offers a variety of office forms and patient-education brochures to insureds at no charge. To order, please use our
online order form. If you would rather receive samples of our materials, contact us at
orders@phyins.com or call us at (206) 343-7300 or 1-800-962-1399 between 8 a.m. and 5 p.m., Monday through Friday.
Risk Management Forms and Sample Letters
The prenatal history questionnaire and prenatal record form are examples of our high-quality forms for physicians. All health care professionals are free to download these two forms.
Prenatal History Questionnaire (
PDF 204 KB)
Prenatal Record Form (
PDF 276 KB)
All of the forms, sample letters, manuals, patient materials, and specialty materials below are available only to members:
Accounting Log for Protected Health Information Disclosures (
Word 48 KB) (
PDF 100 KB)
Advance Consent to Treat Minors (
Word 16 KB) (
PDF 76 KB)
Agreement for Use of Medication in Pain Management (
Word 32 KB) (
PDF 50 KB)
Authorization for Release of Information Regarding Provider Professional Qualifications (
Word 8 KB) (
PDF 80 KB)
Authorization to Use or Disclose Protected Health Information (
Word 24 KB) (
PDF 152 KB)
Clinical Policy for Use of Medication in Pain Management (
Word 36 KB) (
PDF 51 KB)
Closing Your Practice Letter (
Word 12 KB) (
PDF 76 KB)
Complaint/Grievance Resolution Letter (
Word 8 KB) (
PDF 76 KB)
Controlled Substance Prescription Receipt (
Word 12 KB) (
PDF 76 KB)
Denying Request to Access Protected Health Information (
Word 20 KB) (
PDF 80 KB)
Denying Request to Correct or Amend Protected Health Information (
Word 24 KB) (
PDF 84 KB)
Diagnostic Test Tracking Log (
Word 44 KB) (
PDF 100 KB)
Employee Confidentiality Statement (
Word 16 KB) (
PDF 80 KB)
Fax Disclaimer Language (
Word 8 KB) (
PDF 76 KB)
Informed Consent—Patient Education Version (
Word 36 KB) (
PDF 36 KB)
Informed Consent—Standard Version (
Word 24 KB) (
PDF 68 KB)
Informed Refusal of Care Form (
Word 26 KB) (
PDF 11 KB)
Informed Refusal of Care Letter (
Word 34 KB) (
PDF 14 KB)
Kinship Caregivers Informed Consent Declaration for Minors (
Word 16 KB) (
PDF 96 KB)
Lost or Stolen Prescription Attestation Form (
Word 30 KB) (
PDF 52 KB)
Medication Flowsheet (
Word 48 KB) (
PDF 4 KB)
Nonemployee Confidentiality Statement (
Word 20 KB) (
PDF 80 KB)
Notice of Privacy Practices (
Word 76 KB) (
PDF 84 KB)
Notice of Privacy Practices Acknowledgment (
Word 8 KB) (
PDF 104 KB)
Patient Care Agreement Form (
Word 16 KB) (
PDF 76 KB)
Patient Telephone Call Record (message slip) (
PDF 12 KB)
Prenatal Health Questionnaire (
PDF 204 KB)
Prenatal Record Form (
PDF 276 KB)
Prescription Refill Policy (
Word 16 KB) (
PDF 408 KB)
Professional Witness Fee Agreement (
Word 12 KB) (
PDF 76 KB)
Request to Correct or Amend Protected Health Information (
Word 16 KB) (
PDF 84 KB)
Response to Defective Subpoena or Incomplete Request to Disclose Protected Health Information (
Word 20 KB) (
PDF 76 KB)
Revocation of Authorization to Use or Disclose Protected Health Information (
Word 16 KB) (
PDF 76 KB)
Sample Drugs Form (
Word 12 KB) (
PDF 400 KB)
Signature Log (
Word 12 KB) (
PDF 76 KB)
Termination of Care Letter (
Word 12 KB) (
PDF 76 KB)
Upset Patient Letter (
Word 12 KB) (
PDF 76 KB)
Risk Management Manual
Risk Management Reference Guide (
PDF 1537 KB): a manual designed for physicians who want to keep their practices safe from malpractice claims (publication date: November 2007)
To access individual sections and sample forms in the manual, see the
chapter list on our members-only page.
Risk Management Patient Materials
Answers About Anesthesia
(PDF 576 KB)
Having a Healthy Baby
(PDF 824 KB)
How Are We Doing? (
PDF 796 KB)
Labor and Delivery: Choices & Decisions (
PDF 608 KB)
Risk Management Specialty Materials
Anesthesia:
Adult Awake Intubation (
PDF 1.9 MB)
Airway Approach Algorithm (
PDF 60 KB)
Decision Making in Airway Management (
PDF 52 KB)
Emergency Medicine:
Adult Awake Intubation (
PDF 1.9 MB)
Airway Approach Algorithm (
PDF 60 KB)
Chest Pain Evaluation Guidelines (
PDF 60 KB)
Decision Making in Airway Management (
PDF 52 KB)
OB/GYN:
CDC Culture-Based Strategy (
PDF 84 KB)
Forceps/Vacuum Dictation Guide/Operative Note (
PDF 64 KB)
Having a Healthy Baby (
PDF 824 KB)
HELPER for Shoulder Dystocia (
PDF 136 KB)
Labor and Delivery: Choices & Decisions (
PDF 608 KB)
Neonatal Resuscitation Program Reference Chart (
PDF 2.1 MB)
Oxytocin in Use Checklist (
Word 59 KB)
Prenatal Health Questionnaire (
PDF 204 KB)
Prenatal Record Form (
PDF 276 KB)
Pre-Oxytocin Checklist (
Word 64 KB)
Proposed Statement for Informed Consent (
PDF 128 KB)
Sample Infant Code Record (
PDF 276 KB)
Serum Marker Screen Second-Trimester Screening (
PDF 32 KB)
Shoulder Dystocia Delivery Note Addendum (
Word 54 KB)
Shoulder Dystocia Dictation Guide Chart Form Sample (
PDF 72 KB)
More Useful Risk Management Tools
Balancing Risk in the Management of Chronic Pain - Physician and Patient Toolkit (
Word 2.2 MB)
Balancing Risk in the Management of Chronic Pain - Physician Book (
PDF 3.5 MB)
Chest Pain Evaluation Guidelines (
PDF 60 KB)
Coordinated Quality Improvement Program Plan Template (
Word 140 KB)
Cross-Cultural Communication as a Risk Management Issue (
PDF 184 KB)
Death With Dignity Act Summary for Washington and Oregon (
Word 280 KB)
HIPAA Privacy Forms in German, Russian, Spanish, Tagalog, and Vietnamese:
www.awphd.org/Publications/resources_translatedForms.aspx
Infectious Disease Pearls (
PDF 28 KB)
Interagency Guideline on Opioid Dosing (
PDF 212 KB)
Medical Records Self-Assessment Guide (
Word 44 KB) (
PDF 84 KB)
Medication Error Self-Assessment Survey (
Word 64 KB) (
PDF 92 KB)
Patient SAFE Medical Practice Toolkit (
PDF 116 KB)
Patient Telephone Call Record (message slip) (
PDF 12 KB)
Physicians Insurance Guide to Adopting Electronic Medical Records (
PDF 148 KB)
Risk Management Essentials: A Self-Study Course for Medical Office Staff (
PDF 23 KB)
Structuring Your Own Management of Pain - Patient Booklet (
PDF 1.6 MB)
Use Your SMARTS for Opioid Safety (
PDF 200 KB)
