Template Language Guide¶

Quick Summary: Concise, plain-language examples for common DPC practice documents. Use these as starting points — customize for your practice and have an attorney review before use.

Table of Contents¶

• Consent for Treatment
• HIPAA Notice of Privacy Practices
• Financial Policy
• Telehealth Consent
• Authorization for Release of Records
• Controlled Substance Agreement
• After-Hours Policy

Consent for Treatment¶

Purpose: Obtain patient permission for examination and treatment.

Concise Version (~100 words)¶

I consent to examination, testing, and treatment by [Practice Name] and its physicians. I understand that medicine is not an exact science and that no guarantees have been made regarding the outcome of any examination or treatment. I have had the opportunity to ask questions about my care. I understand I may withdraw consent at any time.

Signature: _______________ Date: _______________

Standard Version (~200 words)¶

I, the undersigned, consent to medical examination, diagnostic procedures, and treatment by the physicians and staff of [Practice Name].

I understand that: - The practice of medicine is not an exact science, and no guarantees have been made to me regarding the outcome of examination or treatment - I have the right to ask questions about any proposed treatment and to receive answers I understand - I have the right to refuse any treatment - I may withdraw my consent at any time

I have been given the opportunity to discuss my medical history, current condition, and any questions I have about my care.

Patient Signature: _______________ Date: _______________

If signed by someone other than patient: Relationship to patient: _______________

See Required Documentation for when written consent is needed beyond this general form, and what a procedure-specific consent should include.

Key Elements¶

• Clear statement of consent
• Acknowledgment that outcomes are not guaranteed
• Right to ask questions
• Right to refuse or withdraw consent
• Signature and date
• Space for authorized representative if applicable

HIPAA Notice of Privacy Practices¶

Purpose: Inform patients how their health information may be used and their rights regarding it.

Required Content (Summary)¶

Your Notice of Privacy Practices must explain:

1. How we use your information — Treatment, payment, healthcare operations
2. When we may share without your permission — Public health, legal requirements, safety
3. When we need your written permission — Marketing, most sharing with third parties
4. Your rights — Access records, request corrections, request restrictions (including your right to insist we not tell your health plan about an item you paid for in full out of pocket), receive confidential communications, get a copy of the notice, file complaints
5. Our duties — Maintain privacy, notify you of breaches, follow the notice
6. Contact information — Privacy officer or contact for questions/complaints
7. Substance use disorder (42 CFR Part 2) statements — required since 2026-02-16 if you create, receive, or maintain SUD treatment records

This is a summary, not the full list of required elements — see HIPAA Compliance Basics for everything 45 CFR 164.520(b)(1) requires, including the verbatim header sentence and the effective date.

Plain Language Opening (Example)¶

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Acknowledgment of Receipt (Separate Form)¶

I acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices.

Patient Name (print): _______________ Signature: _______________ Date: _______________

Resources¶

• HHS Model Notices of Privacy Practices (2026 versions; same link used in HIPAA Compliance Basics)
• AMA Practice Management resources (search "HIPAA notice template")

Financial Policy¶

Purpose: Set clear expectations about payment, fees, and financial responsibilities.

DPC-Specific Concise Version¶

[Practice Name] Financial Policy

Membership Fees Your monthly membership fee of $_____ is due on the _____ of each month. Payment is collected automatically via [credit card/ACH].

What's Included Your membership includes [list core services: office visits, telehealth, messaging, etc.]. See your membership agreement for complete details.

What's Not Included Labs, imaging, medications, referrals to specialists, and procedures beyond the scope of primary care are not included in membership fees.

Payment Methods We accept credit cards, debit cards, ACH bank transfer, and HSA/FSA cards.

Failed Payments If your payment fails, we will notify you and attempt to collect within 5 business days. Membership may be suspended after [X] days of non-payment.

Questions Contact us at [phone/email] with any questions about your account.

I have read and understand this financial policy.

Signature: _______________ Date: _______________

A financial policy is a companion document, not a substitute for your membership agreement. See Membership Agreement Essentials for what the agreement itself must cover, and Handling Cancellations & Refunds for what your failed-payment and suspension language needs to say.

Key Elements¶

• Clear statement of fees and due dates
• What is and isn't included
• Accepted payment methods
• Policy for failed payments
• Contact information for questions
• Signature acknowledgment

Telehealth Consent¶

Purpose: Inform patients about telehealth services and obtain consent for virtual care.

Concise Version¶

Consent for Telehealth Services

I understand that telehealth involves the use of electronic communication (video, phone, secure messaging) between me and my physician when we are not in the same location.

I understand that: - Telehealth is not appropriate for emergencies — I should call 911 or go to an ER for emergencies - Technical difficulties may occur and may interrupt or end my session - My physician may determine that telehealth is not appropriate for my condition and request an in-person visit - I have the right to refuse telehealth services

I consent to receive telehealth services from [Practice Name].

Signature: _______________ Date: _______________

Additional Considerations¶

Privacy statement:

I understand that telehealth sessions will be conducted in a private setting on my physician's end, and I will ensure privacy on my end. Sessions may be documented in my medical record.

Technology requirements:

I understand that I am responsible for having appropriate technology (smartphone, tablet, or computer with camera/microphone and internet connection) for video visits.

Interstate practice (if applicable):

I understand that my physician is licensed in [State] and that I must be physically located in [State] during telehealth visits.

See Telehealth Legal Considerations for the full licensed-where-the-patient-is-located rule and the current DEA telemedicine prescribing flexibilities.

Key Elements¶

• Definition of telehealth
• Not for emergencies
• Technical limitations
• Privacy considerations
• Right to refuse
• Geographic limitations (if applicable)
• Signature and date

Authorization for Release of Records¶

Purpose: Obtain patient permission to share medical records with specified parties.

Concise Version¶

Authorization to Release Medical Records

Patient Information Name: _______________ DOB: _______________

I authorize [Practice Name] to release my medical records to: Name/Organization: _______________ Address: _______________ Phone/Fax: _______________

Information to be released: (check all that apply) [ ] Complete medical record [ ] Office visit notes from: _____ to _____ [ ] Lab results [ ] Immunization records [ ] Other: _______________

Purpose: [ ] Continuing care [ ] Personal use [ ] Other: _______________

This authorization expires: _______________ (date or event)

I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken based on this authorization. [Practice Name] will not condition my treatment on whether I sign this authorization. I understand that once my information is disclosed under this authorization, the recipient may redisclose it, and it may no longer be protected by federal privacy law.

Signature: _______________ Date: _______________

The revocation, non-conditioning and redisclosure statements above are all required elements of a valid authorization, not optional wording — see Required Documentation for the complete list and what happens if one is missing.

Key Elements¶

• Patient identification
• Who receives the records
• What information is released
• Purpose of release
• Expiration date
• Right to revoke
• Statement that treatment is not conditioned on signing
• Statement that redisclosed information may lose HIPAA protection
• Signature and date

Controlled Substance Agreement¶

Purpose: Establish expectations for patients receiving ongoing controlled substance prescriptions.

Concise Version¶

Controlled Substance Agreement

I understand that [Practice Name] is prescribing controlled substances to treat my condition. I agree to the following:

1. One prescriber: I will receive controlled substances only from this practice unless approved in advance.

2. One pharmacy: I will use only one pharmacy for controlled substance prescriptions: _______________

3. No early refills: I understand prescriptions will not be refilled early. Lost or stolen medications will not be replaced.

4. Keep appointments: I will attend all scheduled appointments and submit to drug testing if requested.

5. Safe storage: I will keep medications secure and not share them with anyone.

6. Honest communication: I will inform my physician of all medications I take and any substance use.

7. Monitoring: I understand my prescriptions may be monitored through the state prescription drug monitoring program (PDMP).

I understand that violation of this agreement may result in discontinuation of controlled substance prescriptions and/or discharge from the practice.

Patient Signature: _______________ Date: _______________ Physician Signature: _______________ Date: _______________

This agreement is optional under federal law but recommended for chronic controlled substance therapy. See Controlled Substances Compliance for PDMP requirements, DEA registration rules and the current telemedicine prescribing flexibilities that this agreement doesn't cover.

Key Elements¶

• Single prescriber agreement
• Designated pharmacy
• No early refill policy
• Appointment compliance
• Safe storage
• Honest communication
• PDMP monitoring disclosure
• Consequences of violation
• Both signatures

After-Hours Policy¶

Purpose: Set clear expectations about after-hours access and communication.

Concise Version¶

[Practice Name] After-Hours Policy

Emergencies For life-threatening emergencies, call 911 or go to the nearest emergency room immediately.

Urgent After-Hours Concerns For urgent but non-emergency issues after hours, [choose one]: - Call our main number and follow prompts to reach the on-call physician - Send a message through our patient portal (responses within X hours) - Text [phone number] (responses within X hours)

Routine Questions Non-urgent questions should be sent via the patient portal or saved for regular office hours. We will respond within [X] business days.

What is urgent? - New fever over 102°F - Severe pain not controlled by usual medications - Worsening symptoms that concern you - Medication questions that cannot wait

What can wait until office hours? - Prescription refill requests - Appointment scheduling - Forms and paperwork - General health questions

Our commitment: We will respond to urgent messages within [X hours]. Routine messages are answered within [X business days].

See After-Hours Coverage for the coverage models this policy language assumes and more sample policies by model.

Key Elements¶

• Emergency instructions (call 911)
• How to reach physician after hours
• Expected response times
• Definition of urgent vs. routine
• What can wait

General Principles for All Templates¶

Plain Language Guidelines¶

• Use short sentences
• Avoid medical and legal jargon
• Use "you" and "we" instead of "the patient" and "the practice"
• Define any necessary technical terms
• Use bullet points and white space

Legal Review¶

Version Control¶

• Include a version date in the footer of each document
• Review all templates annually
• Update when regulations change

Additional Resources¶

Official Sources: - HHS HIPAA Model Notices - AMA Practice Resources

State-Specific Requirements: - Check your state medical board website - Consult a healthcare attorney in your state

Related kit guides for the full legal requirements behind each example above: - Required Documentation — informed consent and records release - HIPAA Compliance Basics — Notice of Privacy Practices - Telehealth Legal Considerations — telehealth consent - Controlled Substances Compliance — controlled substance agreements - Membership Agreement Essentials and Handling Cancellations & Refunds — financial policy - After-Hours Coverage — after-hours policy

These templates are provided for educational purposes. Always consult with a healthcare attorney before implementing.

Read through and figures checked on 2026-09-23.