- Find An ICS Doctor
- Articles
Featured
Normal Anatomic Variants of the Cervical Spine
Featured
- Recent
- Member Benefits
- Education & Events
- Governmental Relations
- Classifieds
- Advertising
Select Page
illinois chiropractic society
Forms and templates library
Editable forms and templates for your practice.
Do You Need that Perfect Form for Your Practice?
The following forms are researched, flexible, accurate, and easily tailored to your practice needs. ICS members in good standing can download, edit, and continue to utilize these forms and templates for FREE in their offices throughout their membership lives (please see licensing terms and conditions below). Downloading is an easy one-step process – When you select to download a form below, we will take you to your account and automatically download the form.
Click on the form name or the + to expand the category listing. Once expanded, you will find a link to the various forms and templates along with a link to an article that explains how to use the linked form. Jump to your needed category by clicking a category button here:
Consent
Financial
HIPAA
Human Resources
Insurance
Other
Patient Resources
Scope
Good Faith Estimates
Insurance
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
Assignment and Designation of Authorized Representative
ERISA Letters and Requests
MEDICARE ADVANCED BENEFICIARY NOTICE
NOTIFICATION OF NONCOVERED SERVICE
PATIENTS’ RIGHT TO DIRECT PROVIDER NOT TO SUBMIT A CLAIM TO HEALTH PLAN
NON-DISCRIMINATION APPEAL LETTER
ICD-10 Resources
Consent
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
Authorized Relative Certification
Authorization, Consent and Release Template for Patient Photos and Videos
INFORMED CONSENT AND PATIENT NON-COMPLIANCE
Financial
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
FINANCIAL HARDSHIP WAIVERS
FINANCIAL POLICY
HEALTH CARE LIENS
SUBPOENAS TO TESTIFY
| Template | Petition for Fees | Explanation |
NON-DISCRIMINATION APPEAL LETTER
CALCULATING PROFITABILITY FOR PRACTICE SUCCESS
Scope
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
ADVERTISING “PHYSICAL THERAPY
MODIFYING STUDENT PHYSICAL EDUCATION
| Resource | School PE Letter | Explanation |
SCOPE/AUTHORITY TO ORDER
Chiropractic Physician Authority to Perform Occupational Therapy
Patient Resources
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
AN OPIOID EPIDEMIC TOOLBOX
CHIROPRACTIC HEALTH CARE MONTH: RESOURCES
DRUGS OR CHIROPRACTIC CARE FOR LOW BACK PAIN?
| Resource | Low Back Pain Flyer | Explanation |
HIPAA
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
HIPAA BREACH NOTIFICATIONS
HIPAA COMPLIANCE
HIPAA Right of Access
Human Resources
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
EMPLOYEE CONCEALED CARRY
PPACA REQUIRED NOTICE
Mandated Reporter
Notice to Consult with Attorney Re: Covenant Not to Compete or Covenant Not to Solicit
Notice and Authorization for Employee Credit Check
Good Faith Estimates
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
Good Faith Estimates
Other
EMPTY
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
CME TRACKING
CORONAVIRUS (COVID-19) IN THE CHIROPRACTIC PHYSICIAN OFFICE
Office of Inspector General (OIG)
| Template | OIG Compliance Manual | Explanation |
OSHA
The Illinois Chiropractic Society (ICS) grants exclusively to ICS members in good standing (“authorized users”) a non-transferable license to use ICS Forms and Templates above for the purposes set out in the full terms and conditions. Your use of our site and its Forms and Templates constitute your agreement to abide by the Terms of Use and License of ICS Forms and Templates.
As a reminder, this License terminates for any Illinois Chiropractic Society member user at such time as the member is no longer in good standing according to the ICS bylaws. Users who are not in good standing, including without limitation those who are not current in payment of dues, are not authorized to use ICS forms and Templates, and any such use is strictly prohibited.