The forms, documents and policies contained in this 112 page manual have been compiled by Iris Kimberg, MS PT OTR. It is sold as a word document, not a PDF file so that you can edit each page as you see fit – ie. with practice name, etc. Newly updated in 2023 with a 13-page addendum. See additional forms/policies below.
All practices are unique and reflect the individuals that are their creators. Yet there are commonalities that must be present in all practices by virtue of the fact that we are all compelled by similar professional practice acts, work and professional ethics as well as state and federal regulations including OSHA and HIPAA.
The purpose of this book is to offer generic guidelines, policies and forms from which a therapist can then customize their own policies, procedures and forms to best meet their individual practices. Remember that policy and procedure manuals should be reviewed yearly and updated as often as necessary to reflect current standards of practice, new regulations and any changes in state and federal law. Table of contents below
SECTION ONE: FORMS
FOR DIRECT PATIENT CARE:
1. Initial Pediatric Intake Form
2. Generic Evaluation Forms -Pediatric OT, PT, ST
3. Generic Progress Re-evaluation Note
4. Generic Discharge Form
5. Assignment of Benefits Form/Patient Notification of Billing/Cancellation/Discontinuance of Services Policy/Financial Policy Form
6. Pre and Prompt Payment Discount and Financial Hardship Waivers
7. Authorization for Release of Confidential Information
8. Notice of Patient Privacy Practice/ Patient Information Consent Form
9. Pediatric Patient Satisfaction Survey
10. Referral Source Satisfaction Survey
11. Pediatric Photo/Video Release Form
12. Caretaker Permission Form
13. Onsite Class Waiver Form
SECTION TWO: FORMS/ POLICY STATEMENTS FOR GENERAL OFFICE PROCEDURES
1. Incident Reporting and Form
2. Reporting of Child Abuse
3. Confidentiality, Release and Handling of Information including HIV Information
4. Confidentiality for Emails/Faxes
5. Emergency Preparedness Plan and Business Interruption Plan
6. Health and Safety Issues Including Universal Precautions, Infection Control/ Handwashing Procedures
7. HIPAA Policy and Procedures and Business Associates Agreement BAA for HIPAA
8. Clinical Chart Review Form
9. Policy for Management of Lice
10. Vaccine Policy Statement
SECTION THREE: FORMS FOR HIRING THERAPISTS/NON CLINICAL STAFF
1. Application Form, Orientation and Minimum Requirements of Therapists
2. Reference Forms
3. Clinical Competency Review Form
4. Employee Health Assessment
5. Hepatitis B Consent/Decline Form
6. Freedom from Impairment Form
7. On Site Clinical Competency Form
8. Sample Employee Handbook
9. Code of Ethics – OT, PT ST
10. Sample Probationary or Annual Performance Review for Staff
SECTION FOUR: BOILER PLATE GENERIC CONTRACTS
1. Sample Temporary Personnel Services Agreement
2. Sample Home Care Personnel Services Agreement
3. Sample Contract for School District Service Provision
4. Sample Independent Contractor Agreement
5. Sample Employee Contract
6. Job Descriptions OT, OTA, PT, PTA, Practice Manager
7. Non Disclosure Agreement
Addendum added in 2023 -13 pages