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A practice management consulting and training firm working for and with physicians since 1985

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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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
New, Deleted, and Revised Codes for ASCs
OIG Work Plan Excerpt
Financial & Reporting
Billing Service Evaluation Checklist
Daily Close Form
Monthly Financial Indicators Form
Sample Patient Financial Policy
Personnel
Billing Knowledge Assessment Quiz
Exit Interview Form
Standard Employment Application
AR & Reimbursement
Account Receivable Follow-Up Training Tool
Implementation Checklist: Maximizing Clearinghouse Services
Medicare Carrier Websites by State
Minor Procedure Letter at the Time of Service Letter
Prompt Pay Statutes by State
Sample Collection Letters
Sample Registration & Insurance Forms
Silent PPO Appeal Letter
Surgery Cost Quotation Form
Verification of Eligibility Worksheet
Internet Tools
Patient Internet Needs Assessment
Privacy Policy Draft
Sample Internet Use Policy
Coding & Compliance
2006 Allergen Immunotherapy for Medicare Beneficiaries
Appeal Letter for Modifier 59
CMS Regional Offices
GPCIs by Carrier and Locality
Hospital Visit Coding Card
Payor Advice Letter
Request for Consultation
Surgical Booking Worksheet
Other
Retaining Medical Records article
Sample Identity Theft Prevention Program (Red Flags Rule)
Sample Referring Physician Survey
State Licensing Rules for Estheticians
Strategic Planning Assessment

KarenZupko & Associates, Inc. • 625 North Michigan Avenue, Suite 2225 • Chicago, Illinois 60611 • 312.642.5616 • FAX: 312.642.5571

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