Practice policy templates.

Appointment attendance policy

[Practice Name] reserves appointment time specifically for each patient. Appointments cancelled or rescheduled with less than [24/48] hours' notice, or missed without notice, are recorded as late cancellations or no-shows.

• A fee of [$X] applies to no-shows and late cancellations for office visits, and [$Y] for procedure or surgical consultation slots. This fee is the patient's responsibility and is not billable to insurance.
• After [3] no-shows in [12] months, future visits may require a deposit or same-week scheduling, and continued care may be reviewed under our patient dismissal policy.
• Post-operative patients: missed post-op visits jeopardize your recovery. Our team will contact you to reschedule immediately, and your surgeon will be notified.
• Fees are waived for documented emergencies at the practice's discretion.

Patients are notified of this policy at registration, and reminders are sent by text before every visit. Signature: [Patient name, date]

Termination of the physician-patient relationship

[Date] · Sent by certified mail, return receipt requested · [Patient name and address]

Dear [Patient name]: This letter provides notice that [Practice/Physician name] is ending our physician-patient relationship, effective [date at least 30 days out, per state requirements]. The reason for this decision is [state neutrally: repeated missed appointments, non-adherence to the agreed treatment plan, conduct toward staff; or omit per counsel's guidance].

Until the effective date, we will remain available to you for urgent and emergency care. We encourage you to establish care with another orthopedic physician promptly; your county medical society or your insurer's directory can help you locate one. Upon receipt of a signed authorization, we will forward a copy of your medical records to your new physician. [If in active post-op care: describe the transition plan for the global period.]

Sincerely, [Physician name and credentials]

A HIPAA-valid authorization must contain

• Patient name and identifying information, and a specific description of the information to be disclosed
• Who is authorized to disclose, and to whom the disclosure goes
• Purpose of the disclosure (patient request is sufficient)
• An expiration date or event, the patient's signature and date, and notice of the right to revoke
• Statements on conditioning of treatment and potential redisclosure

Operational rules for your form: verify identity before releasing, log every disclosure, apply your state's fee schedule for copies, and meet your state's turnaround requirement [commonly 30 days or less; several states are shorter]. Special categories (behavioral health, substance use) carry stricter rules.

Telephone access and after-hours policy

• Business-hours calls are answered live with a maximum acceptable abandonment target of [X%]; voicemail is not an acceptable destination for a live caller during business hours.
• After-hours clinical calls follow the practice's written triage protocol, with urgent calls escalated to the on-call provider and all calls documented in the EMR.
• Emergencies are always directed to 911 first, in every greeting and every protocol.
• Refill requests are never resolved on the phone by non-clinical staff or automation; they are documented and routed to the clinical team.
• The on-call schedule is maintained in [system] and every escalation records who was contacted, how, and when.

Our after-hours triage protocol template and phone scripts plug directly into this policy.