Create Narrative Templates

• Click on the Chart Talk Logo
• Click on Documents
• Click on Narrative Templates

• Click ‘Create’

1. Name of the template
2. A description of the template
3. Dynamic Variable reference library – Select the variable that you want to insert and the @variable will display for you to copy (ctrl + c) and paste (ctrl + v)
4. IsAssignable – When true this document can be assigned to a patient to review and sign, similar to the OAT forms
5. Content of the template

Click Save

Learn more about @variables that you can include in these templates.

Watch our webinar on assigning documents and Chart Talk Bookings

YouTube – Patient engagement: Different ways for patients to access their portal and assigned forms.

Example Form

***For Demonstration Purposes Only. For Legal requirements in your location please consult your local association for local resources available to you.***

FINANCIAL POLICY

Thank you for choosing @Clinic for your chiropractic needs. We appreciate the opportunity to serve you and are committed to providing you with the best possible care.

As part of our service to you, we try to contain the ever-rising cost of healthcare. In an effort to do this, we have implemented the following Financial Policy. Please read and sign below. Your cooperation in following our credit policy will allow for a prompt settlement of your claim.

It is the patient’s or responsible party’s responsibility to see that all charges are paid in full, even if the insurance pays less than the actual bill for services.
As a courtesy to you, we will file all medical claims, with the primary and secondary insurance. However, you must provide us with current copies of your insurance and notify us immediately if there are changes in this information.

It is your responsibility to obtain ANY referrals required by your insurance company and update them as needed. If you do not have a current referral you may be asked to reschedule your appointment or sign a waiver stating that you will be responsible for payment of charges.

Co-payments (HMO, PPO) are to be made at time of service. Payments by Visa, MasterCard, check or exact change is appreciated.

Medicare Patients: We submit and accept assignment on all Medicare claims. As a courtesy, we will file to your secondary insurance.

No Insurance: If you do not have health insurance, a payment equaling half of the cost of your first visit will be collected at the time of your first visit. A $25.00 payment will be collected at the time of each return office visit. Any outstanding balance is due immediately upon receipt of statement. Payment by Visa, MasterCard, check or exact change is appreciated.

Divorce: In divorce situations, the parent who brought the child in is responsible for payment of the bill. We will submit to the necessary insurance carriers.

1. Contact @Clinic at *CLINIC PHONE NUMBER HERE* if you have any questions regarding your account before any payment is past due.

2. Accounts that are 90 days past due may be referred to a collection agency unless payment arrangements have been made with our business office. If you have a financial hardship, please let us know so that we might set up payment arrangements. You agree in the event you default on any payments due and owing this office for services rendered, you will pay for any and all cost of collection from such payments due and owing, including, without limitation, responsible for attorney’s fees, third party collection agency fee court costs and any other such costs.

3. There will be $25.00 service charge for any returned checks.

4. FINALLY, you have a contract with your insurance company – we do not. It is your responsibility to communicate with the insurance company if you are not happy with your insurance company’s determination of benefits for your claim.

Practice/Dr. Name: __ @Clinic ____ Today’s date:__ @Today __

In the event that I default in any payments due and owing this doctor for such services, I will pay any 3rd party collection agency fees. Agreed to as of the date first written above.

I have read and received a copy of the Financial Policy and understand its contents. I hereby assign all medical benefits (to include major medical, Medicare, private insurance and other health plans) to @Clinic. I also authorize @Clinic to release information regarding my chiropractic care to my insurance company to obtain payment.