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Key Points
- The health record is a record
of services rendered. It provides justification for all treatment
provided and information upon which to base subsequent care.
- If your
clinic has a computer-based system, the majority of the forms you
need should be included in the software package that you use. Otherwise,
you will need to select forms to use for many day-to-day clinic operations.
- HIPAA requires clinics
that transmit health information in an electronic transaction
to use a standard format.
- To
account for income received from services rendered to patients,
clinics need a billing and collections system.
- Completing
the prior approval form (if one is necessary) and the superbill
are the only two billing functions normally delegated to clinical
staff. The remaining functions take place in the front office,
back office, or billing department.
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