Patient Registration Form Template in MS Word

The patient registration form template is word template for register and record the new patient information. This template is almost identical with earlier form template, only this one supposed for printing purpose. Like its early version, it can be used for clinics, small hospital, and healthcare.

 

TEMPLATE OUTLINE

There are some elements in patient registration form template:

Patient Registration Form Template Header

Enter the clinic or hospital name here. Below the big header, there are fields for Form Date and PCP ID field. PCP ID may be served as primary key. Or you can add form number or ID field as primary key.

patient registration form sample
patient registration form sample

Patient Information

The tables about recording the patient information. The fields are:

  • Patient Last, First, and Middle Name
  • Patient Title: for calling: Mr., Mrs., Miss, or Ms.
  • Marital Status: Single, Married, Divorced, Separated, or Widowed.
  • Legal Name: fill if the patient ever changed their name or using other name.
  • Birth Date
  • Age
  • Gender
  • Addresses fields: Street Address, PO box number, City, State, and ZIP Code
  • Social Security Number: outside of US, you can enter the patient identification ID.
  • Home or Cell Phone Numbers
  • Occupation
  • Employer name and Phone
  • Referral: how do you referred or find the clinic/hospital. If you select Doctor or Other, include their name or their relation to you.
  • Other family member: enter other patients related with current patient.
patient registration form doc
patient registration form doc

Financial and Insurance Information

This is the tables for who will pay the medical bill and insurance setup. The fields are:

  • Responsible person for the bill: Name, Birth Date, Address, and Phone Number
  • Is responsible person is patient too in current clinic or hospital?
  • Responsible person job field: Occupation, Employer Name, Address, and Phone
  • Is the patient Covered by Insurance?
  • Insurances: enter the Insurance Company name in your country or places, before printing or given to the patients
patient registration form pdf
patient registration form pdf

Below one is about the insurance subscriber information, which come in 2 insurance companies, one is primary while the other one is secondary. The fields are all same, except the secondary has no Co-Payment field:

  • Subscriber Name, SSN, birth date
  • Subscriber insurance group, policy, and co-payment
  • Patient relationship to Subscriber
patient registration forms for a medical office
patient registration forms for a medical office

In Case of Emergency

Where to enter who to be called or contacted if something happened to patient. The fields are:

  • Name
  • Relationship with patient
  • Home and Work Phone
patient registration form template pdf
patient registration form template pdf

Patient Registration Form Template Signing Agreement

It has fields for Patient’s sign (or Guardian if the patient still underage or disabled) and Date of signing. By signing this, the patient has been agreed with clinic/hospital terms.

 

HOW TO USE

To use patient registration forms for a medical office, first edit or replace the placeholder text. This placeholder text mainly the information for choices, such as Insurance Company name in Insurance Information section. You can change the header with the clinic/hospital header including logo, name, and contact details.

Next, you can change the font formatting style such as font type, size, or color. You can add watermark by going to Design tab > Watermark > Custom Watermark. Then navigate to the pictures location or create one.

This template is not using macros for form, unlike the previous one. Patient registration form doc is simply for printing and manual writing purpose. The radio button or check boxes in this patient registration form template is mainly pictures or symbol instead and not clickable.

You can turn this into digital use by using Developer tab by going to File > Options. On appeared window, choose Customized Ribbons, and tick the Developer tab before click OK. Secondly, you can convert it as patient registration form pdf. Then, using Adobe Acrobat or other application to edit the patient registration form template pdf to fill the form.

 

CONCLUSION

You can use this patient registration form sample right ahead or use it as the sample for your own template. You can add more details, such as patient health history or disabilities.

The patient registration form template can be downloaded after you click:

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Authorization Letter to Get Medical Records

The authorization letter to get medical records is the word template for requesting the medical records. This authorization letter is signifying that you give permission for the third party or authorized party in the letter to receive your medical records.

 

LETTER OUTLINE

This authorization letter to get medical records template has several elements:

Your Details

The part where you enter your details. The fields are:

  • Your Name
  • Street Address
  • City, State, and Zip Code Address
  • Date: when this authorization letter to get medical records is written and given.
authorization to release medical records form sample
authorization to release medical records form sample

Doctor Details

The part where you enter your doctor details, which this authorization letter to release medical records will be given to. The fields are:

  • Doctor Name
  • Clinic or Hospital Name
  • Clinic or Hospital Street Address
  • Clinic or Hospital City, State, and Zip Code Address
sample letter to release medical records
sample letter to release medical records

Content

On this template content, you may find the sample letter to release medical records context. You can simply write your own letter content.

sample authorization letter to pick up medical records
sample authorization letter to pick up medical records

The grey text is the placeholder that you supposed to change. The content itself has several parts:

  • Subject or Title: tell about the request title, your full name, Date of Birth, and SSN. If you live outside US, you can change the SSN into Identity Card Number or Patient ID.
  • Content Opening: it opened with greeting words. In this opening, tell about your medical condition that has been treated before and the date of the treatment.
  • Third Party: The party which you give authorization to receive and see your medical letter. It include the organization or individual name, Street Address, and City Address.
  • Content Closing: tell about thank you, and inform to pay the cost of medical copies.
authorization letter to release medical records
authorization letter to release medical records

Signature

This is where you place your signature or anything as proof that you write the letter and give the authorization to release medical records to third party. It consist of the closing greetings, and your name. The Name field is autogenerated.

authorization to release medical records to third party
authorization to release medical records to third party

 

HOW TO USE

To use the authorization letter to get medical records, simply replace the placeholder text with your own information. Follow the rules and tips to write a good authorization letter.

It is advised to write the content in less than 5 paragraphs and not too long. The content should be short and direct but polite. You should enter the important elements like the ones provided in authorization to release medical records form sample.

Modifying authorization letter to get medical records template is possible. Due to formality, it is not suggested to change the format even the text font, size, or color. Adding picture or watermark is not necessary at this point. You can make the text alignment to Justify through or add subheadings if it really needed. You can add company header if the medical record is requested by your company.

 

EXAMPLE

Here is other sample authorization letter to pick up medical records, in content only:

I am writing this letter to request copies of any medical records of mine that you have. I have understood that according to the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations, I am entitled to have copies of my medical records.

I was treated in ABC Hospital from 21 June 2016 to 30 June 2016. I would like copies of all of my blood test results, imaging studies, operative reports, as well as notes from doctors and nurses, consultations with specialists, referrals and any other record in my medical file.

I understand you may charge a reasonable fee for copying the records, as well as for postage to mail the reports to the above address. However, you will not charge for time spent locating the records.

I hope to receive the above records within 30 days as specified under HIPAA or receive a letter stating the reason for any delay. I can be reached at (123) 123-4567 or a jonahg@mail.com if you have any questions.

Thank you for your attention.

CONCLUSION

To download authorization letter to get medical records, click one of these:

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Employee Referral Form Template in MS Word

Employee referral form template is the word template for recording the candidates for job position through employee referral program. Employee referral program is the employee recruitment method which organization identify potential candidates from their existing, active or non-active employee social networks or circles. In this template, the referral programs may contain award or commission for successful referral, through sometimes it is not.

This referral form template can be used for any business or companies, like startup company or even big companies.

 

DESIGN

There are some elements in employee referral form template:

Header

Where you enter the company information. The fields are logo and company name.

employee referral form doc
employee referral form doc

Guidelines

Sometimes called rules. This is where you enter the guideline for the program in applicant referral form, like the requirement for the job applications, award conditions and rules, or recruitment timeline. Currently, there are 5 rules that has been provided in this template. You can change the placeholder texts such as time, amount, and such.

candidate referral form template
candidate referral form template

Employee Information

Where you enter the employee information. This employee is the one who refer the candidates. The fields are:

  • Employee Name
  • Employee ID
  • Email: personal or company email
  • Date: Referral date, date when the employee fill and deliver this referral form.
  • Department
  • Telephone: personal telephone preferred

Referral Information

Where you enter the job candidate information. The fields are:

  • Candidate Name
  • Email
  • Telephone
  • Position Referred for: the job position to apply. It could be the department name.
  • Why this candidate is qualified for this position: the reason, or the positive qualifications which made the candidate is eligible and matched for the job position. It is suggested to add pros and cons.

HR Information

Enter the additional information for employee referral form template and job recruitment progress. The fields are:

  • Date received: date when the HR received the employee referral form doc.
  • Hired: the hiring status of the referred candidates.
  • Interviewed: the interview status, has it done yet or not. If done, enter the interview date.
  • Award Date: when the employee will be awarded for the referral, if the candidates hired following the rules in guidelines.
employee referral form example
employee referral form example

 

HOW TO USE

applicant referral form
applicant referral form

To use candidate referral form template simply input the record into the provided fields. To change picture, select the placeholder picture. Right click and select change picture. Navigate to your picture location and click OK.

You can change the text color, font type, and font size. You can print this employee referral form template blank for manual writing. It set on A4 paper. Since the fields are actually part of tables without border, you may need to adjust the table width and length if you change the paper size or margin.

Aside for job application referral, you can use and modify this employee referral form word as other referral form, such as club membership refer program or such.

You can add watermark by going to Design tab > Watermark > Custom Watermark. Then navigate to the pictures location or create one.

Additionally, you can add UI feature into this form, such as radio button, drop down menu, or checkbox. To add it, you will need Developer tab. Open the Developer tab by going to File > Options. On appeared window, choose Customized Ribbons, and tick the Developer tab before click OK.

On the Developer tab > Controls Group, insert the feature. Each feature has different method to use, so you may need skills in creating UI to use this tool. Open the developer kit for more information. You can add macros as well.

 

EXAMPLE

Here is the employee referral form example for Marketing Program:

employee referral form word
employee referral form word

 

CONCLUSION

The template can be used for printing or digital sending. You can use this template right ahead or use it as the sample for your own template. You can add more details, such as candidates education, experience, or form ID.

The template is free to download or modify. You can download employee referral form template after you click:

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MLA Outline Template in MS Word

MLA outline template is the word template for writing the outline in MLA (Modern Language Association) format. It can be used for anything. It can be outline template for research paper, thesis, or science journal articles. This template can be used for students or modified to professor on research or project.

Outline is a synopsis, summary of a written work. It can be used for define the plan if you use it for project outline.

 

DESIGN

On the right top, on header, enter the student’s last name. The page number will automatically generated. The MLA outline template has several elements:

MLA Outline Template Identity

Part to enter who done the essay assignment or whom paper it is. The Identity consist of these fields:

  • Student Name
  • Instructor Name: who give or should receive the paper. You can add the lecturer or instructor code if needed.
  • Course Number: the course ID or Name. It can be changed into the Science Journal name if it for research purpose.
  • Date: paper created or written on Date.
mla format template
mla format template

MLA Outline Template Content

It is for writing the summary from the overview paper or project plan. On the very top, it has Title and Subtitle. Current placeholder text content consists of hint, tips, and instruction on how to write paper using MLA format.

mla outline template doc
mla outline template doc

After the title and text paragraphs, it has the template for:

Table

Each table should have the Table Number on top, then the Table Title below the Table Number. The table design style could be changed, however make sure that the table design is not too flashy because the paper should be formal.

Below the table, add the table source, where do you get the table. The source should include the author, journal or book taken from, and the pages.

mla outline template word
mla outline template word

Chart Title

Unlike table, Chart number is put under the chart picture, started with “Fig. (Number)”. After the number, it followed by chart title. You can add the chart title inside the chart too, and the figure title as description instead.

Under the chart title, you can add source if needed. The writing on source should have author, journal or book, and pages too.

Citation

This citation is in content, along with the text. MLA outline template explain clearly how to write the citation paragraph or sentence, as well enter the source such as author name, book or journal, year, and sometimes pages. Unlike reference, the Citation is brief and shorter.

Reference

This is where you write used idea or supporting documents for creating the paper, mostly the full reference from citation source. The format to writing the reference can be seen inside the MLA outline template doc.

outline template for research paper
outline template for research paper

 

HOW TO USE

To use the MLA outline template, simply write or type in the placeholder text. Follow the rules and tips on the placeholder text to write a good outline.

If you want to add picture, go to Insert tab > Picture > navigate to picture location. After you insert the picture, follow the Figure writing format in Chart Title.

mla outline template
mla outline template

It is advised to add Section Heading for easier reading. The header started with number and the Section title in capital. If you add subheading, you can use numeric or different format.

Sample of numeric heading:

  1. Persian Carpet

1.1. History

1.2. Distribution

  1. Art Technique

Sample of different format headings:

Persian Carpet

                        History

                        [content]

                        Distribution

Art Technique

Modifying MLA outline template word is possible. However, MLA format template is formal, it is not suggested to change the format even the text font, size, or color. You can make the text alignment to Justify through.

 

CONCLUSION

The MLA style specifies guidelines for formatting manuscripts and using the English language in writing. This template not only provide the section for MLA outline, but the tips and guide to write. This template could be for writing an essay.

To download MLA outline template, click one of the:

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