Front office templates for specialty practices

We keep each appointment for you. When one is missed or cancelled late, another patient who needed a skin check could not have it.

Cancelling or changing an appointment

Please tell us at least [24] hours before your appointment, or [48] hours before a procedure. Call us on [phone number] or reply to your reminder text.

Reminders

We send a reminder [3 days] and [1 day] before each appointment. This policy applies whether or not a reminder reaches you.

Fees

If you miss an appointment or cancel with less than [24] hours' notice, we charge [amount in USD]. For a procedure, the fee is [amount in USD]. Your payer does not pay this fee.

Repeated missed appointments

After [3] missed appointments in [12 months], we may ask for a deposit before booking your next one.

Your agreement

I have read this policy and agree to it.

• Patient name: [ ]
• Signature: [ ]
• Date: [ ]

Insurance

Please bring your insurance card and photo ID to every visit. We check your coverage before each visit and tell you if anything has changed.

You pay your copay at check-in. You are responsible for your deductible, coinsurance and any service your plan does not cover.

Estimates

Ask us for an estimate before any procedure. If you don't have insurance, or choose not to use it, you have the right to a good faith estimate of your costs.

Paying a balance

We send your statement by text and email, with a secure link to pay. Balances are due within [30] days of the statement.

If you can't pay in full, ask us about a payment plan before the due date.

Payment methods

We accept [cards, bank transfer, HSA and FSA cards].

Your agreement

I have read this policy and agree to it.

• Patient name: [ ]
• Signature: [ ]
• Date: [ ]

What to collect

• The patient's name and date of birth.
• The medication, its strength and how it is taken, as written on the label.
• The pharmacy's name and location.
• When it was last filled, and how many doses are left.
• Any new symptoms or side effects, in the patient's own words.

Where it goes

• Every request goes to [the prescribing provider / the clinical team's queue] in [your record system].
• Requests for isotretinoin and any biologic go to the prescribing provider only.
• A request that mentions new symptoms or side effects goes to [nurse or clinical lead] the same day.
• Controlled substances follow federal and state prescribing rules. Never promise a controlled-substance refill on the phone.

When the patient must be seen first

Your providers set this rule, for example: [no visit in the last 12 months]. Offer the patient the first opening.

What to tell the patient

Front desk

I've sent your request to [provider]. We handle refill requests within [2] business days, and we'll text you when it's at your pharmacy.

[Date]

[Payer name], Appeals department, [address or fax]

• Patient: [name], date of birth [date]
• Member ID: [ID]
• Reference or case number: [number]
• Requested: [treatment, medication or test], [CPT, HCPCS or NDC code]
• Denied on: [date]

I am writing to appeal your decision of [date] to deny prior authorization for [treatment] for my patient, [name]. [Treatment] is medically necessary for the reasons below.

Diagnosis

[Diagnosis and ICD-10 code], diagnosed on [date].

Treatment so far

[Each treatment tried, with dates, dose and result, and why it was stopped.]

Why this treatment

[The clinical reasons, matched to the criteria in your coverage policy [policy name and number], and to published guidelines.]

The reason given for the denial

The denial states: "[reason, quoted]". [The answer to that reason, point by point.]

Request

Please approve [treatment] for [duration]. I am available for a peer-to-peer review on [phone number].

Enclosed: [visit notes, test results, photographs, previous approvals and denials].

• [Provider name, credentials]
• [NPI]
• [Practice name and address]
• [Signature]