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.

Attention Internet Explorer Users!
If you double click on a Word Document, and you are asked for a username and password, simply click "cancel" and the form will load properly.

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.

When the file says .pdf...
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.

Financial & Reporting
Billing Service Evaluation Checklist
Daily Close Form
Monthly Financial Indicators Form
Sample Patient Financial Policy
Exit Interview Form
Standard Employment Application
AR & Reimbursement
Prompt Pay Law Information by State
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
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
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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