Consent to Disclose Personal Health Information (PHI) Form and recommendations for obtaining consent to disclose patient health information to a third party. July 12, 2024 Sample Forms State Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care
Consultation for Dental Treatment Form for a mutual patient’s physician to confirm medical condition, diagnosis and/or fitness for treatment October 23, 2015 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care
Dental History Form for capturing a patient’s at-home oral hygiene, dental concerns and treatment history October 23, 2015 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation Patient Care
Diagnostic X-rays Required Letter Sample letter to inform and educate a patient of necessary X-rays to continue dental treatment October 23, 2015 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care
Dispensing Products Acknowledgment Form to document products that are dispensed to a patient (does not apply to medications) November 23, 2022 Sample Forms State Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington General Liability Patient Care
Emergency Phone Screening to Determine Appointment Immediacy Form to facilitate patient screening by phone and determine immediacy, appointment need or emergency care January 25, 2017 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation Patient Care
Esthetic Approval (Crowns, Veneers, Bridges) Form for esthetic approval of crowns, veneers or bridges October 23, 2015 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care
Esthetic Approval and Case Completion (Dentures and Partials) Form for esthetic approval of dentures or partials and permission to proceed with their completion October 23, 2015 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care
Failed Appointments Letter Sample letter to a patient who continues to miss dental appointments to address needs and consequences October 23, 2015 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability
Follow Up for Biopsy Letter Sample letter to a patient about referral for evaluation and/or biopsy of a suspicious area or lesion October 24, 2018 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation Patient Care