Forms and Downloads

Save yourself time and money! Customize KZA's useful forms, checklists, and other tools to suit your practice's unique needs.

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It's easy to Download and customize these Microsoft Word Documents!
Many of our practical forms and checklists have been posted here as Microsoft Word documents. Click on the Document you want, and the computer will open in Word (if you have that application). Once you have opened the document, save it to your hard drive or disk and customize it to your needs.

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A few tools have been posted as .pdf files, which require Adobe Acrobat Reader to view. If you don't have this software you can download it for free from the Adobe website.

2012 Resources
2012 ICD-9-CM Diagnosis Codes Effective October 1, 2011
2012 OIG Work Plan Excerpt
Appeal Forms
Check out the Dispute & Appeal Process section of AETNA's website for detailed information and for state-specific appeal forms.
CIGNA Request for Payment Review and Appeal
UHC Claim Reconsideration Request Form
2011 Resources
OIG Work Plan Excerpt
New, Deleted, and Revised Codes for ASCs
Financial & Reporting
Monthly Financial Indicators Form
Daily Close Form
Sample Patient Financial Policy
Personnel
Billing Knowledge Assessment Quiz
Exit Interview Form
Standard Employment Application
AR & Reimbursement
Implementation Checklist: Maximizing Clearinghouse Services
Prompt Pay Statutes by State
Sample Collection Letters
Account Receivable Follow-Up Training Tool
Surgery Cost Quotation Form
Verification of Eligibility Worksheet
Sample Registration & Insurance Forms
Silent PPO Appeal Letter
Medicare Carrier Websites by State
Minor Procedure Letter at the Time of Service Letter
Internet Tools
Privacy Policy Draft
Sample Internet Use Policy
Patient Internet Needs Assessment
Coding & Compliance
2006 Allergen Immunotherapy for Medicare Beneficiaries
CMS Regional Offices
GPCIs by Carrier and Locality
Hospital Visit Coding Card
Request for Consultation
Payor Advice Letter
Surgical Booking Worksheet
Appeal Letter for Modifier 59
Other
Sample Identity Theft Prevention Program (Red Flags Rule)
State Licensing Rules for Estheticians
Retaining Medical Records article
Strategic Planning Assessment
Sample Referring Physician Survey