Sample Forms, Checklists, and Letters

You deserve top-notch risk resources to help you lessen uncertainty and exert more control. Editable document templates can help you save time. Using sample documents can help establish effective communication methods among your patients and healthcare staff. 

Since laws vary from state-to-state, please contact a Risk Resource Advisor to discuss specific situations, or if you would like us to review your template modifications.

Sample Forms

Against Medical Advice Guideline |
2 pages • 8.5 x 11 in • 33 KB
Against Medical Advice Discharge Form |
1 page • 8.5 x 11 in • 33 KB
Chain of Command Flowchart |
1 page • 8.5 x 11 in • 52 KB
Chain of Command Policy |
2 pages • 8.5 x 11 in • 63 KB
Confidentiality Agreement |
1 page • 8.5 x 11 in • 489 KB
Informed Consent Form |
1 page • 8.5 x 11 in • 50 KB
Informed Consent Form, Dental |
1 page • 8.5 x 11 in • 47 KB
Medication Education Form for Patients |
1 page • 8.5 x 11 in • 256 KB
Medication Refill Guideline |
1 page • 8.5 x 11 in • 251 KB
Medication Refill Log |
1 page • 8.5 x 11 in • 249 KB
Event Occurrence Form |
1 page • 8.5 x 11 in • 56 KB
Patient Complaint Form |
1 page • 8.5 x 11 in • 107 KB
Refusal of Treatment Form |
1 page • 8.5 x 11 in • 40 KB
Tracking and Follow-Up Log |
1 page • 8.5 x 11 in • 145 KB
Telephone Triage Guideline |
2 pages • 8.5 x 11 in • 37 KB

Checklists

Closing a Practice Checklist |
2 pages • 8.5 x 11 in • 55 KB
Dental Sedation/Anesthesia Checklist |
1 page • 8.5 x 11 in • 70 KB
Employee (Licensed) Competency Skills Checklist |
2 pages • 8.5 x 11 in • 243 KB
Employee (Unlicensed) Skills Checklist |
2 pages • 8.5 x 11 in • 61 KB
Informed Consent Checklist |
1 page • 8.5 x 11 in • 44 KB
Informed Consent Checklist, Dental |
1 page • 8.5 x 11 in • 28 KB
Organizational Suicide Risk Assessment Checklist |
1 page • 8.5 x 11 in • 27 KB
Recording Conversations Checklist |
2 pages • 8.5 x 11 in • 45 KB

Patient Letters

Patient Notification Letters |
3 pages • 8.5 x 11 in • 39 KB
Withdrawal from Care or Termination Letter |
1 page • 8.5 x 11 in • 38 KB

Contact a Risk Resource Advisor

If you have a risk management question and would like to speak with someone, call 844.223.9648 for a Risk Resource Advisor or email RiskAdvisor@ProAssurance.com.

Do you have a suggestion about additional forms, checklists, or letters you’d like to see? Or a suggestion about how we can improve an existing form? Please let us know

Risk Resource Guidelines

ProAssurance insureds also have access to our Risk Resource Guidelines. These Guidelines provide information on over 20 topics, covering the most vexing subjects in healthcare today.