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

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Assignment and Designation of Authorized Representative

 

TemplateAssignment and Designation of Authorized RepresentativeExplanation

 

ERISA Letters and Requests
FormAssignment and Designation of Authorized RepresentativeExplanation
TemplateLetter of Appeal Post Service Claim - Lack of Medical Necessity Insufficient information Provided by Plan to RespondExplanation
TemplateRequest for Summary Plan DescriptionExplanation
TemplateRequest for Summary Plan DescriptionExplanation
TemplateRequest to legal department or request to forward to legalExplanation
TemplateLetter of Appeal Post Service Claim - Lack of Medical Necessity Sufficient Information Provided by Plan to AppealExplanation
TemplateLetter of Appeal Post Service Claim - Plan Exclusion Request for Summary Plan Description OnlyExplanation
TemplateLetter of Appeal Pre-Service Claim - Lack of Medical Necessity Insufficient information Provided by Plan to RespondExplanation
TemplateRequest for Summary Plan DescriptionExplanation
TemplateRequest to Legal Department or Request to Forward to LegalExplanation
ResourceImportant Definitions and ResourcesExplanation

MEDICARE ADVANCED BENEFICIARY NOTICE

 

FormAdvance Beneficiary Notice of Noncoverage ABN - EnglishExplanation
FormAdvance Beneficiary Notice of Noncoverage ABN - English Large PrintExplanation
FormAdvance Beneficiary Notice of Noncoverage ABN - SpanishExplanation
ResourceForm Instructions Advance Beneficiary Notice of NoncoverageExplanation

NOTIFICATION OF NONCOVERED SERVICE
FormNotice of Non-Coverage Under Private Insurance or Health PlanExample

PATIENTS’ RIGHT TO DIRECT PROVIDER NOT TO SUBMIT A CLAIM TO HEALTH PLAN
TemplateRequest to Restrict Use or Disclosure (Release) ofExample

NON-DISCRIMINATION APPEAL LETTER
TemplateSection 2706 Template LetterExplanation

ICD-10 Resources
ResourceICD-10 Quick Reference GuideExplanation

Consent

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Authorized Relative Certification
TemplateAuthorized Relative CertificationExplanation
Authorization, Consent and Release Template for Patient Photos and Videos
TemplateAuthorization, Consent and Release Template for Patient Photos and VideosExplanation
INFORMED CONSENT AND PATIENT NON-COMPLIANCE
TemplateParental Guardian Consent to Chiropractic Examination and Care of MinorExplanation
TemplateConsent to Chiropractic Examination and CareExplanation

Financial

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FINANCIAL HARDSHIP WAIVERS
TemplateFinancial Hardship WaiversExplanation
FINANCIAL POLICY
FormNotice of Non Coverage FormExplanation
TemplateFinancial Policy TemplateExplanation
HEALTH CARE LIENS
TemplateNotice of Health Care Professional LienExplanation
SUBPOENAS TO TESTIFY
TemplatePetition for FeesExplanation
NON-DISCRIMINATION APPEAL LETTER
TemplateSection 2706 Template LetterExplanation
CALCULATING PROFITABILITY FOR PRACTICE SUCCESS
ResourceOverhead Worksheet SampleExplanation

Scope

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ADVERTISING “PHYSICAL THERAPY
ResourceIDFPR Letter: Use of Term “Physical Therapy"Explanation
MODIFYING STUDENT PHYSICAL EDUCATION
ResourceSchool PE LetterExplanation
SCOPE/AUTHORITY TO ORDER
TemplateICS Member Scope of Practice Authority to Order Physical Therapy Form LetterExplanation
TemplateGeneric Scope of Practice Form LetterExplanation
Chiropractic Physician Authority to Perform Occupational Therapy
TemplateChiropractic Physician Authority to Perform Occupational TherapyExplanation

Patient Resources

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AN OPIOID EPIDEMIC TOOLBOX
ResourceA Natural Solution to the Opioid CrisisExplanation
CHIROPRACTIC HEALTH CARE MONTH: RESOURCES
ResourceChiropractic SavesExplanation
ResourceWhat Does A Full Life Look LikeExplanation
ResourceChiropractic Health Care Month: Social Media LibraryExplanation
DRUGS OR CHIROPRACTIC CARE FOR LOW BACK PAIN?
ResourceLow Back Pain FlyerExplanation

HIPAA

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HIPAA BREACH NOTIFICATIONS
TemplateHIPAA Breach NotificationExplanation
TemplateHIPAA Breach Media NotificationExplanation
HIPAA COMPLIANCE
FormPatient Consent FormExplanation
FormBusiness Associate AgreementExplanation
FormPatient AuthorizationExplanation
TemplatePrivacy PolicyExplanation
TemplateHIPAA Physical Control Maintenance Records LogExplanation
HIPAA Right of Access
FormHIPAA Right of Access RequestExplanation
FormHIPAA Right of Access Request PDFExplanation

Human Resources

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EMPLOYEE CONCEALED CARRY
TemplateWorkplace Weapons Ban PolicyExplanation
PPACA REQUIRED NOTICE
FormNew Health Insurance Marketplace Coverage Options and Your Health CoverageExplanation
Mandated Reporter
FormAcknowledgment of Mandated Reporter StatusExplanation
Notice to Consult with Attorney Re: Covenant Not to Compete or Covenant Not to Solicit
TemplateNotice to Employee Restrictive CovenantExplanation
Notice and Authorization for Employee Credit Check
FormNotice and Authorization for Employee Credit CheckExplanation

Good Faith Estimates

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Good Faith Estimates
TemplateGood Faith Estimate Language for WebsiteExplanation
FormPatient Good Faith Estimate FormExplanation
TemplateRight to Receive A Good Faith EstimateExplanation

Other

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CME TRACKING
FormContinuing Medical Education Category I (60 Hours Minimum)Explanation
FormContinuing Medical Education Category II (90 Hours Minimum)Explanation
CORONAVIRUS (COVID-19) IN THE CHIROPRACTIC PHYSICIAN OFFICE
ResourceUpdated Face Covering PosterExplanation
FormTelehealth Consent FormExplanation
FormCovid Screening Document - for patientsExplanation
FormCovid Screening Document- For StaffExplanation
TemplateCOVID-19 Template Letter for Patients of Chiropractic PhysiciansExplanation
TemplateCOVID-19 Template Letter for Patients of Chiropractic Physicians in SpanishExplanation
TemplateLayoff Letter TemplateExplanation
TemplateClosing Notice Pandemic TemplateExplanation
TemplateSample FFCRA Exclusion NoticeExplanation
ResourceCovid Face Covering RequirementExplanation
ResourceCovid-19 Stop SignExplanation
ResourceCovid-19 Infection Control PolicyExplanation
Office of Inspector General (OIG)
TemplateOIG Compliance ManualExplanation
OSHA
TemplateBloodborne Pathogens PolicyExplanation

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.