Professional Practice Resources



These valuable resources are available to NAN Affiliate, Associate, Professional, Fellow, and Emeritus members.
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The Professional Affairs and Information Committee (PAIC), Practice Information Exchange (PIE) product, designated as THE PAIC PIE PACK, was developed by the PAIC as a toolkit for practice. The goal of the PIE Pack is to facilitate an exchange between NAN members, providing documents that members have found useful in their practice.
 
These forms and brochures are examples only and are not officially endorsed by NAN, the NAN PAIC, or the NAN Board of Directors.


New Patient Information

  • Appointment Letter
  • Patient Information Form
  • Patient Registration Form 
  • Patient Registration Form
  • Patient Registration Form

Consent

  • Consent for Psychological Diagnostic Clinical Interview Consultation and Treatment Form 
  • Consent for Treatment Form 
  • Consent for Evaluation Form 
  • Consent for Evaluation Form
  • Consent for Neuropsychological Evaluation Form 
  • Limits of Confidentiality Form 
  • Psychology Services Agreement 
  • Policies and Procedures of Practice 

Release of Information

  • Patient Release of Information Form 
  • Authorization for Release of Information Form 
  • Authorization for Release of Information Form
  • Consent for Confidential Release of Information Form 
  • Test Release Form 
  • Release of Health Information Form

Intake

  • Initial Intake Form 
  • Adult Intake Form 
  • Child/Adolescent Intake Form 

HIPAA

  • HIPPA Notice for Practice 
  • Patient Termination Letter 

Referral

  • Referral Letter 
  • Prescription for Services Form 
  • Referral Thank You Letter 
  • Referral Thank You Letter (Records Enclosed) 
  • Patient Referral Form

Billing forms for patients

  • Billing and Information Contract 
  • Billing Notes Sample - Billing Slips 
  • Balance Due Letter
  • Balance Due Letter
  • Balance Due Letter
  • Balance Due Letter
  • Delinquent Payment Letter

Insurance waivers and other insurance information for patients

  • Insurance Coverage Limitation on Professional Service Form 
  • Insurance Coverage Limitation
  • Neuropsych Coverage Letter
  • Billing Sheet 

Legal forms

  • Consent For Forensic Evaluation
  • Consent For Non-Forensic Evaluation

Student/Teacher

  • Student Recommendation Letter 
  • Teacher Questionnaire 

Sample contracts

  • Business Contract (for Accountant) 
  • Information and Billing Contract


These forms should be modified according to your own state's requirements, and you may wish to have them reviewed by an attorney familiar with those requirements prior to your use.