Skip to content

General tips

  • Fill out forms with the patient, at a visit scheduled for that purpose. Have your medical assistant or scheduler ask about any forms you’re expected to deal with. These are not a by-the-way item. They take real time, and if you’re guessing at answers because the patient isn’t there, you’ll be doing it again.

  • Don’t be afraid to punt. If you are not qualified to fill out the form without a lot of guesswork, say so. That applies to any part of a form or to the whole thing. For example, time off following surgery is the purview of the surgeon.

  • Lawyers will send you forms asking you to summarize, for their benefit, weeks or years of medical records. You are not required to fill these out at all. You can send the office notes instead, which should not require your input at all. But you might save your patient some hefty hourly legal fees if it wouldn’t take much of your time.

  • Give the minimum information the form actually requires. Anything extra is ammunition for corporate lawyers. “The patient has a qualifying diagnosis” is among my favorite phrases. If they need details, the agency requesting the information will have to justify each and every one. The one caution here: an answer so vague that the reviewer can’t act on it usually comes back to you as a second form. Minimal is the goal; useless is not.

  • Never volunteer family history on an employment-related form. Federal law bars employers from acquiring genetic information, which includes family medical history. Well-drafted forms carry a warning telling you not to provide it. Poorly drafted ones don’t. Leave it out either way.

  • Put you EHR to work for you. Need a detailed medication list written in a half-inch space? “See attached.”

  • If you’re asked for a letter rather than a form, start with a draft from a HIPAA-appropriate AI tool — Our only corporate-authorized LLM is CoPilot. You can exports records from Epic, upload to CoPilot, and prompt it with the information requested. This saves a lot of time; I’m a slow writer. Use only tools your organization has approved for PHI, and read every line before you sign it. You own what’s over your signature.

  • You can’t send forms or letters to a third party without a signed release. You can always hand the completed form to the patient, or send it through the portal, and let them do what they need with it. If they want you to send it, have them date the release to cover at least the next year so they aren’t signing a new one every time. You must use our corporate release form; the patient may provide one with the form, but we can’t use it. (A few disclosures don’t need a release — workers’ compensation in most circumstances, and anything required by law — but “when in doubt, get the release” has never gotten me in trouble.)

  • Always save a copy. Patients lose things. So do I. And you will often be asked to “tweak” one answer on a ten-page form.

  • Never backdate, and never certify something you can’t support from the chart. Most of these forms are signed under penalty of perjury, and several of them are federal documents. A note that says a patient was incapacitated on a date you never saw them is the one item on this list that can end a career.

  • Know your practice’s policy on charging. Form completion is generally not a covered service, and many practices charge a flat administrative fee. There is a CPT code for special reports (99080), but payers rarely pay it. Whatever your policy is, make sure the front desk states it up front, before the form lands on your desk.

  • Set a turnaround expectation and put it in writing. Though I have the patient in fornt of me, I can’t write a thoughtful three-page letter in the middle of a busy clinic day. I tell them to do this right, I’ll need five business days. Patients who know that stop calling on day two, and the ones with a real deadline tell you about it at the visit instead of afterward.