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 Management advisor to discuss specific situations, or if you would like us to review your template modifications.

Sample Forms

COVID-19 Acknowledgement for Medical Practices |
1 page • 8.5 x 11 in • 17 KB
Sample Informed Consent Form |
1 page • 8.5 x 11 in • 110 KB
Sample Telehealth Informed Consent Form |
1 page • 8.5 x 11 in • 101 KB
Sample Telehealth Informed Consent Form During COVID-19 Pandemic |
1 page • 8.5 x 11 in • 19 KB
Against Medical Advice Guideline |
2 pages • 8.5 x 11 in • 33 KB
Against Medical Advice Physician Documentation Checklist |
1 page • 8.5 x 11 in • 29 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
Event Occurrence Form |
1 page • 8.5 x 11 in • 56 KB
Florida Consent For Pelvic Exams |
1 page • 8.5 x 11 in • 18 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
Notice of Inappropriate Behavior |
1 page • 8.5 x 11 in • 37 KB
Patient Authorization to Release Medical Information Form |
1 page • 8.5 x 11 in • 58 KB
Patient Behavior Agreement |
1 page • 8.5 x 11 in • 27 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
Suggested Topics for Policy and Procedure Manuals |
2 pages • 8.5 x 11 in • 128 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
Observation and Precautions Used With Permission of ASHRM |
6 pages • 8.5 x 11 in • 78 KB

Checklists

Closing a Practice Checklist |
2 pages • 8.5 x 11 in • 55 KB
Communication Skills Checklist |
2 pages • 8.5 x 11 in • 68 KB
Dental Sedation/Anesthesia Checklist |
1 page • 8.5 x 11 in • 70 KB
Emergency Department Behavioral Health Risk Assessment Checklist |
1 page • 8.5 x 11 in • 25 KB
Employee (Licensed) Competency Skills Checklist |
2 pages • 8.5 x 11 in • 48 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
Senior Care Hurricane Preparedness Checklist |
2 pages • 8.5 x 11 in • 172 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 Management Consultant

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 Management Guidelines

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