Document Library

1500 Claim form

      • 1500 02-12 Fill In The Blank With Calculations(Log in or Sign up to download.)
      • 1500 Claim Form Instruction Manual 2012 02-v2(Log in or Sign up to download.)

      CPT - Modifiers, Injections, Prolonged Services, Miscellaneous Services

          • Telephone Calls And On-line Evaluation (Log in or Sign up to download.)

          Correspondence & Fight Back Letters

              Denial of E&M with Acupuncture

            • Denial Of E&M Code Billed With Acupuncture PDF(Log in or Sign up to download.)
            • Insurance Disputing Fees

            • Usual Customary And Reasonable Fee Reduction (editable)(Log in or Sign up to download.)
            • Usual Customary And Reasonable Fee Reduction PDF(Log in or Sign up to download.)
            • Insurance requesting a refund

            • Insurance Requesting A Refund (editable)(Log in or Sign up to download.)
            • Insurance Requesting A Refund PDF(Log in or Sign up to download.)
            • Insurance Requesting A Refund, Extended Response PDF(Log in or Sign up to download.)
            • Maintenance and Medical Necessity Denials

            • Acupuncture Medical Necessity Denial PDF(Log in or Sign up to download.)
            • Maintenance Care Denial (editable)(Log in or Sign up to download.)
            • Maintenance Care Denial PDF(Log in or Sign up to download.)
            • Patient Collection

            • Patient Late Pay When They Receive The Check (PDF)(Log in or Sign up to download.)
            • Patient Late Pay When They Receive The Check (editable)(Log in or Sign up to download.)
            • Patient Late Pay When They Receive The Check(Log in or Sign up to download.)
            • Patient Late Pay (PDF)(Log in or Sign up to download.)
            • Patient Late Pay (editable)(Log in or Sign up to download.)
            • Personal Injury

            • Attorney Holding Med Pay(Log in or Sign up to download.)
            • Attorney Holding Med Pay(Log in or Sign up to download.)
            • Attorney Late Payment With Signed Lien(Log in or Sign up to download.)
            • Attorney Late Payment With Signed Lien(Log in or Sign up to download.)
            • Attorney Status Of Claim(Log in or Sign up to download.)
            • Attorney Status Of Claim(Log in or Sign up to download.)
            • Attorney Cover Letter With Lien(Log in or Sign up to download.)
            • Attorney Cover Letter With Lien(Log in or Sign up to download.)
            • Attorney Negotation To Reduce Settlement Rejection(Log in or Sign up to download.)
            • Attorney Negotation To Reduce Settlement Rejection(Log in or Sign up to download.)
            • Attorney Not Paying Settled Claim(Log in or Sign up to download.)
            • Attorney Not Paying Settled Claim(Log in or Sign up to download.)
            • Attorney Paying Reduced Amount Rejection(Log in or Sign up to download.)
            • Attorney Paying Reduced Amount Rejection(Log in or Sign up to download.)
            • Deposition Expert Witness Fees(Log in or Sign up to download.)
            • Deposition Expert Witness Fees(Log in or Sign up to download.)
            • Excess Med Pay HMO Primary(Log in or Sign up to download.)
            • Excess Med Pay HMO Primary(Log in or Sign up to download.)
            • Excess Med Pay No Primary Health Insurance(Log in or Sign up to download.)
            • Excess Med Pay No Primary Health Insurance(Log in or Sign up to download.)
            • Patient Late Payment Of Settled Claim 2(Log in or Sign up to download.)
            • Patient Late Payment Of Settled Claim 2(Log in or Sign up to download.)
            • Patient Late Payment Of Settled Claim(Log in or Sign up to download.)
            • Patient Late Payment Of Settled Claim(Log in or Sign up to download.)
            • Termination of PPO Contract

            • Termination Of PPO Contract (PDF)(Log in or Sign up to download.)
            • Termination Of PPO Contract (editable)(Log in or Sign up to download.)
            • Timely Filing Dispute

            • Timely Filing Dispute (PDF)(Log in or Sign up to download.)
            • Timely Filing Dispute (editable)(Log in or Sign up to download.)
            • Withdrawal from care

            • Withdrawal From Care (PDF)(Log in or Sign up to download.)
            • Withdrawal From Care (editable)(Log in or Sign up to download.)
            • Documentation

                  External Causes of Injury ICD9 & ICD10 Codes

                      • E Codes ICD9 External Causes Of Injury(Log in or Sign up to download.)
                      • V, W, X, Y, & Z Codes ICD 10 Morbidity & Health Status Codes(Log in or Sign up to download.)

                      Financial Agreements

                          Cash and-or Insurance

                        • Financial Policy & Agreement (PDF)(Log in or Sign up to download.)
                        • Financial Policy & Agreement (editable)(Log in or Sign up to download.)
                        • Credit Card Authorization

                        • Credit Card Authorization For Past Due Payments(Log in or Sign up to download.)
                        • Financial Hardship

                        • Financial Hardship Agreement (PDF)(Log in or Sign up to download.)
                        • Financial Hardship Agreement (editable)(Log in or Sign up to download.)
                        • Insurance

                        • Health Insurance Acupuncture (PDF)(Log in or Sign up to download.)
                        • Health Insurance Acupuncture (editable)(Log in or Sign up to download.)
                        • Personal Injury (auto accidents)

                        • Personal Injury Financial Agreement (PDF)(Log in or Sign up to download.)
                        • Personal Injury Financial Agreement (editable)(Log in or Sign up to download.)
                        • Forms (History, exam, consultation, lien, assignment of benefits)

                              Assignment of Benefits

                            • Assignment Of Benefits(Log in or Sign up to download.)
                            • Examination

                            • Examination Report (single Page)(Log in or Sign up to download.)
                            • Review Of Systems(Log in or Sign up to download.)
                            • History, Consultation & Examination

                            • Case History Including Accident Information (2 Pages)(Log in or Sign up to download.)
                            • History, Consultation & Examination (4 Pages)(Log in or Sign up to download.)
                            • History, Examination Detailed (8 Pages) PDF Acupuncture 2016 Update(Log in or Sign up to download.)
                            • History, Examination Detailed (8 Pages) Editable Acupuncture 2016 Update(Log in or Sign up to download.)
                            • Patient History Update(Log in or Sign up to download.)
                            • Personal Injury Questionnaire(Log in or Sign up to download.)
                            • Personal Injury Lien

                            • Notice Of Doctors Lien(Log in or Sign up to download.)
                            • SOAP & Daily Notes

                            • Treatment Notes, Single Page(Log in or Sign up to download.)
                            • HCPCS Orthotics and DME Common Codes

                                  HIPAA Privacy Notices

                                      • Business Associate Agreement Acupuncture (editable)(Log in or Sign up to download.)
                                      • Business Associate Agreement Acupuncture PDF(Log in or Sign up to download.)

                                      Informed Consent

                                          • Acupuncture Arbitration Agreement And Informed Consent - FED(Log in or Sign up to download.)
                                          • Informed Consent Acupuncture - California(Log in or Sign up to download.)
                                          • Informed Consent Acupuncture- Federal(Log in or Sign up to download.)

                                          Insurance Acupuncture Coverage Policies

                                              Aetna

                                            • Aetna Acupuncture Clinical Policy Bulletin 0135 Updated 2017(Log in or Sign up to download.)
                                            • Blue Cross and Blue Shield

                                            • Acupuncture Guidelines Evicore (BCBS Diagnosis Pages 270-271)(Log in or Sign up to download.)
                                            • Anthem Acupuncture Clincal Guideline CG-ANC-03(Log in or Sign up to download.)
                                            • Excellus Blue Cross Blue Shield Acupuncture Policy(Log in or Sign up to download.)
                                            • Regence Blue Cross Blue Shield Acupuncture Coverage(Log in or Sign up to download.)
                                            • Cigna

                                            • Cigna Acupuncture Medical Coverage Policy 2017(Log in or Sign up to download.)
                                            • Health Net

                                            • Health Net Acupuncture(Log in or Sign up to download.)
                                            • HealthPartners

                                            • HealthPartners Acupuncture Coverage(Log in or Sign up to download.)
                                            • United Health Care

                                            • United Health Care Acupuncture Policy(Log in or Sign up to download.)
                                            • Insurance Billing Protocol and Sample Bills

                                                  • Acupuncture Insurance Billing Protocol Step-by-Step(Log in or Sign up to download.)
                                                  • Group Practice Or Corporation Acupuncture Billing(Log in or Sign up to download.)
                                                  • Initial Acupuncture Visit - E&M With Acupuncture(Log in or Sign up to download.)
                                                  • Subsequent Acupuncture Visit With Multiple Units Of Acupuncture(Log in or Sign up to download.)
                                                  • Subsequent Acupuncture Visit With Therapy(Log in or Sign up to download.)

                                                  Insurance Verification Form

                                                      • Insurance Verification Acupuncture(Log in or Sign up to download.)

                                                      Outcome Assessments & Disability Indexes

                                                          Balance

                                                        • Balance Test - Tinetti(Log in or Sign up to download.)
                                                        • Berg Balance Scale(Log in or Sign up to download.)
                                                        • Concussion

                                                        • Acute Concussion Evaluation(Log in or Sign up to download.)
                                                        • Depression

                                                        • Depression Assessment(Log in or Sign up to download.)
                                                        • Extremities

                                                        • Disabilities Of The Shoulder And Hand(Log in or Sign up to download.)
                                                        • Lower Extremity Functional Scale(Log in or Sign up to download.)
                                                        • Gait

                                                        • Gait Assessment - Tinetti(Log in or Sign up to download.)
                                                        • Headache

                                                        • Headache Disability Index(Log in or Sign up to download.)
                                                        • Pain & Health Survey

                                                        • Fear Avoidance Behavior Questionnaire(Log in or Sign up to download.)
                                                        • Fear Avoidance Beliefs Questionnaire(Log in or Sign up to download.)
                                                        • General Pain Index(Log in or Sign up to download.)
                                                        • McGill Pain Questionnaire(Log in or Sign up to download.)
                                                        • McGill Short Form(Log in or Sign up to download.)
                                                        • Pain Scale With General Pain Index(Log in or Sign up to download.)
                                                        • Patient-specific-functional-scale(Log in or Sign up to download.)
                                                        • Picture Pain Disability(Log in or Sign up to download.)
                                                        • SF36 General Health Survey(Log in or Sign up to download.)
                                                        • SF36 Scoring(Log in or Sign up to download.)
                                                        • Sleepiness Scale

                                                        • Epworth Sleepiness Scale(Log in or Sign up to download.)
                                                        • Spine

                                                        • Copenhagen Neck Disability(Log in or Sign up to download.)
                                                        • Neck Disability Index(Log in or Sign up to download.)
                                                        • Neck Disability Scoring Method(Log in or Sign up to download.)
                                                        • Oswestry Low Back Disability Index(Log in or Sign up to download.)
                                                        • Oswestry Scoring Method(Log in or Sign up to download.)
                                                        • Roland Morris (Low Back)(Log in or Sign up to download.)
                                                        • TMJ

                                                        • TMJ Questionnaire(Log in or Sign up to download.)
                                                        • Superbill

                                                              • Acupuncture Superbill (editable With MS Excel)(Log in or Sign up to download.)
                                                              • Acupuncture Superbill ICD10 Update(Log in or Sign up to download.)

                                                              Treatment Guidelines

                                                                  Acupuncture General Guidelines

                                                                • Acupuncture Evidence Based Treatment Guidelines(Log in or Sign up to download.)
                                                                • Acupuncture And Electroacupuncture TreatmentGuidelines(Log in or Sign up to download.)
                                                                • Chronic Pain Disorder

                                                                • Chronic Pain Disorder (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Non-Acute Pain Medical Treatment Guideline (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Complex Regional Pain Syndrome

                                                                  Cumualtive Trauma

                                                                • Cumulative Trauma Conditions (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Extremities

                                                                • Carpal Tunnel Medical Treatment Guideline (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Knee Injury Medical Treatment Guideline (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Lower Extremity Injury (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Shoulder Injury (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Shoulder Injury Medical Treatment Guideline (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Spine

                                                                • Cervical Spine Injury (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Low Back Pain (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Mid And Low Back Injury Medical Treatment Guideline (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Neck Injury Medical Treatment Guideline (searchable For Acupuncture)(Log in or Sign up to download.)
                                                                • Thoracic Outlet Syndrome (searchable For Acupuncture)(Log in or Sign up to download.)