AHLA AHLA's Guide to Healthcare Legal Forms, Agreements, And Policies, Second Edition with CD-ROM (Non-Members)

BINDER 1

Accountable Care Organizations
Accountable Care Organization (ACO) Contract Language
Contracting with ACOs/Practice Tips for Health Plan
Data Sharing within ACOs/Contract Checklist

Alternative Dispute Resolution
Arbitration Agreement (Separate from the Admission Agreement)
Arbitration Clause for Insertion into Admission Agreement
Dispute Resolution--Sample Contract Provisions

Business Transactions
Asset Purchase Agreement
Bill of Sale
Captives Trusts Comparisons
Clinical Acquisitions Checklist
Closing Checklist Documents and Actions
Confidentiality Agreement
Due Diligence Checklist
Due Diligence Request for Affiliation with Community Hospital System, Inc.
Health System Due Diligence Request List
Hospital Merger and Acquisition Agreement/Sample Provisions
Hospital-Physician Joint Venture Unwind Checklist
Hospital Services Agreement
Indemnification Agreement
Initial Due Diligence Request and Transaction Evaluation for Health Care Center
Letter of Intent
Management Services and Office Sharing Agreement
Master Service and Sublicense Agreement
Non-Disclosure Agreement #1
Non-Disclosure Agreement #2
Option Agreement
Request for Consent to Assignment
Vendor Contract Review/Compliance Checklist

Clinical Trials and Research
Billing for Clinical Research Services, Items and Tests
Billing for Investigational Devices and Drugs Policy
Clinical Trial Agreement
Exempt Research Checklist
Exempt Research Statement
FDA Regulatory Due Diligence Drug Manufacturer Checklist
FDA Regulatory Due Diligence Drug Manufacturer Document/Information Request
HIPAA Authorization Forms for Clinical Research Involving Serum/Tissue Banking
Informed Consent for Off-Label Use of a Drug or Device
Informed Consent to Participate in Research
Insurance Coverage Analysis for Patients Enrolled in a Clinical Trial
Material License Agreement for Use with Industry
Policy for the Recruitment of Subjects

Conflicts of Interest
Conflict of Interest Statement Trustee/Officer/Employee
Conflict of Interest Survey Form
Conflicts of Interest Annual Disclosure Questions
Medical Device Evaluation Committee/Procedures for Committee (MDEC) Independent and Conflicts of Interest
Model Conflict of Interest Policy for Medical Staff
Model Conflict of Interest Policy for Officers and Directors
Model Conflict of Interest Policy for Physicians
Policy Regarding Conflicts of Interest
Policy Regarding Conflicts of Interest--Board

Corporate Compliance Programs
Antitrust Compliance Guidelines
Appointment of Appropriate Senior Personnel to Oversee the Corporate Responsibility Program (CRP) Policy
Billing Practices Compliance Objectives
Compliance and Anti-Fraud Programs--Sample Contract Provision
Compliance Communication, Reporting, and Investigation Policy
Compliance Plan Effectiveness Scorecard
Compliance Policy and Plan for Ambulatory Surgery Center
Corporate Integrity Agreements ("CIAs") and Consent Decrees: Summary of Requirements
Corporate Responsibility "Score Card"
Dashboard Compliance Metrics
File Memo Re: Compliance Hotline Response
Glossary of Key Compliance Terms
Grant Assessments Audit Plan
Healthcare Compliance Questionnaire
Integrated Data Network Compliance Program Policy
Involvement in Compliance Checklist
Model Corporate Responsibility Program (CRP) Policy
Notice to Agents Policy
OIG Hospital Compliance Program Guidance Worksheets
Policy on Cooperation with Regulators and Investigators
Policy on Discipline for Corporate Responsibility Program--Related Infractions
Policy to Support and Promote the CRP as an Evaluation Factor for Supervisors and Managers
Senior Executive Involvement in Compliance Program Checklist

Facility Operations
Ambulatory Surgical Center License and Registration Checklist
Checklist for Operation Room
Clinic Certification and License Checklist
Clinical Training Agreement
EMTALA Compliance Checklist
Evidence of Community Need Checklist
Gross Time-Share Lease Agreement
Hospital Licensing Checklist
Medical Office Lease Agreement
PPACA Compliance Checklist for Physician-Owned (or Invested) Hospitals
PPACA Primary Care Training and Enhancement Grants Checklist
PPACA Tax-Exempt Hospital Requirements Checklist
Pharmacy Services Agreement
Regulatory Filing Checklist
Selected Provisions for Consulting Engagement Letters

Fraud and Abuse
Disclosure Form for Physician or Physician Family Member Financial Relationships with Hospital Effective Responses to Threat of Whistleblowers' Claims Checklist
Financial Relationship: Healthcare Objectives Assessment
Gift Policy
Hospital/Physician Relationships Policy
How to Operationalize Stark Checklist
Memorandum of Understanding with U.S. Department of Justice
Non-Monetary Physician Gift Benefit and Business Meal Tracking Form
Officer's Certification of Compliance/Physician Gifts
OIG Advisory Opinion Exemplar Request
Physician Subsidy Recruitment Form
Prohibition on Employing, Contracting, or Granting Privileges to Excluded Individuals and Entities: Policy
Provision of Gifts, Travel, Lodging, Entertainment, and Education--Guidance from Trade Associations
Self-Disclosure Best Practices Checklist
Stark Drafting Checklist
Suspect Joint Ventures Checklist
Tolling Agreement
Tracking for Incidental Benefits and Non-Monetary Compensation
Vendor Relations--Frequently Asked Questions (FAQs)
Vendor Visitation and Interaction Policy

Governance
Ambulatory Surgery Center Agreement with 501(c)(3)
Board Compensation Value Worksheet
Community Need Checklist
Compensation Committee Charter
Compensation Philosophy
Compensation Resolutions Relating to Executive Compensation
Confidentiality Policy for Board of Directors
Disqualified Person Status Checklist
Disqualified Person Worksheet
Guide Sheet for Processing Health Care Provider IRC 501(c)(3) Exemption Applications
Rebuttable Presumption Checklist
Sarbanes-Oxley Implementation Recommendations
Sarbanes-Oxley Notice to Outside Counsel
Tax Compliance Objectives

Health Information Exchanges
Health Information Exchange User Agreement
Health Information Exchange Participant Policies and Procedures
Health Information Organization Participation Agreement
Provider Checklist for Joining Health Insurance Exchange

Health Information Technology
Checklist for Electronic Health Records Item or Service Donations
Correcting Errors in Electronic Health Records Checklist
Electronic Trading Partner Agreement
HITECH Act Checklist
HITECH Act Glossary
Identity/Medicare Theft Program Policy
Information Services Remote Access Agreement with Clinician Checklist
IP and Technology Transfer Policy for Faculty
Letter for Data Removal
Patient Identification Policies
Records Management/Retention
Security Regulation Requirements
Technology Policy

Health Plan Contracting
Assignment--Sample Contract Provisions
Audits by Payor--Sample Contract Provisions
Definition of "Payor"--Sample Contract Provisions
Dispute Resolution--Sample Contract Provisions
Managed Care Plan Sample Clauses
Payment--Sample Contract Provisions
Pharmacy--Sample Contract Provisions
Provider Participation Contract and/or Agreements
Provider-Friendly Sample Contract Provisions
Provider Services and License Agreement
Ratio of Cost to Charges Worksheet
Silent PPO--Sample Contract Provisions

Internal Investigations
Document Retention Memorandum for Internal Investigation
Email for Investigation Memo
Internal Investigation Delegation of Authority
Internal Investigations Policy
Internal Processes and Best Practices Checklist
Interview Scheduling Script
Investigation Closure Memo
Investigation/Engagement Memo
Investigative Work Plan Consideration Checklist
Subpoena for Internal Investigation

BINDER 2

Labor and Employment
Agreement to Submit to Random Drug and Alcohol Testing and Required Counseling
Blogging Policy
Checklists for Unionization
Classification of Workers as Employees or Independent Contractors Policy
Code of Conduct for ABC Home Care--Sample
Confidentiality and Network Access Agreement
Drug Testing Policy
Electronic Communications Policy
E-mail Usage Policy for Healthcare Organizations
Employee Relocation Agreement
Employment Agreement/Sample Provisions
Exit Interviews Policy
Fair Labor Standards Act (FLSA) Compliance Checklist
Grievance Checklist for Hospitals
Guidelines for Participation in Online Communities
Immigration Information Sheet
Letter to Former Employees Regarding Confidential Business Information
Non-Solicitation/Non-Distribution Policy
Professional Administrative Services Employment Agreement
Social Media Policy
Sponsorship and Immigration Fees Policy
Surgery Center Code of Conduct
Telecommuting Agreement
Total Compensation Tally Sheet
Wellness Program Legal Checklist
Whistleblower Employee Handbook Language

Legal Services
Agreement for Professional Legal Services
Attorney Response to Request for Legal Advice/Confidentiality and Privilege
Client Questionnaire
Contract Legal Review Certification Form
Contract Term Sheet
Document Request Checklist
Draft Engagement Letter for Expert Witness
Employment and General Litigation Assessment Form
Guidelines for Defense Counsel
Guidelines for Responding to Search Warrants
In-House Counsel Legal Subject Matter Staffing Chart
In-House Counsel Quality Audit Checklist
Joint Defense Agreement
Legal Services Staffing Matrix
Negotiation Strategy Report
Review of Valuation Checklist
Request for Proposal to Serve as Preferred Outside Counsel for the ABC Health System
Witness Preparation Guidelines for Non-Party Witnesses

Long Term Care
Acknowledgement and Indemnification Form/Home Health Private Duty Provider
Ancillary Services Agreement/Acute Care Hospital
Assisted Living Disclosure Statement (Texas)
Assisted Living Facility Adverse Incident Reports (Florida)
Authorized Services for Private Duty Aides and Home Health Agency Personnel Providing Services at ABC Community
Ethical Questions for Ethical Committee Regarding Medication Administration when a Resident with Dementia Refuses Medication
Evacuation Transfer Form
Guidelines for the Employment of Private Duty Care Providers
Home Health Documents for Private Duty Care Providers
Long Term Care Facility Lease Agreement
Medical Director/Advisor Services Timesheet
Medication Management Protocol
Nursing Home Emergency Operations Plan (Louisiana)
Nursing Home Resident Census for Disaster Evacuation Planning
Private Duty Care Provider Registration and Information Form
Rules of Conduct for Private Duty Care Providers
"Under Arrangement" Agreement Between SNF and Supplier--Sample Agreement
Waiver and Release Form for Private Duty Care Providers

Medical Group Practices
Hospital-Physician Group Coverage Agreement
Integrated Medical Group Business Plan
Integrated Medical Group Professional Limited Liability Company
Medical Office Lease Agreement
Physician Practice Valuation Checklist
Practice Closure Checklist
"System Investment in Practice" Provision/Clinic Asset Purchase Agreement

Medical Staff Issues
Annotated Sample Provisions in Medical Staff Bylaws
Citizenship Criteria Policy/Institutional Citizenship
Consent for Substance Abuse Testing
Credentials Policy
Disruptive Practitioner Policy
Fair Hearing and Appellate Review Plan
Fitness for Duty/Clinical Agreement
Fitness for Duty/Interview Documentation
Fitness for Duty/Policy
Fitness for Duty/Return to Work Agreement
Hearing Officer Engagement Letter
Hearing Officer Introductory Letter to Legal Counsel for Parties to Medical Staff Hearing
Hearing Officer Introductory Statement to Hearing Committee and Parties
Impaired Practitioner Policy
Letter to Practitioner Regarding Adverse Recommendation and Right to Hearing
Medical Staff Appointment Bylaws
Medical Staff Appointments Restrictions for Non-Profits
Notification of Revocation of Medical Staff Membership or Denial of Appointment to Medical Staff Based on Conflict of Interest Criteria
Professional Management Division Policies and Procedures Checklist

Patient Care Policies
Abuse Reporting FAQs
Administration of Medications Sample Policy
Behavior Management & Antipsychotic Medicine Checklist
Chest Pain Evaluation/Clinical Documentation Guideline
Consent for Internal Use of Patient Information
Discovery of Alcohol, Chemical Substances or Weapons in a Patient's Possession--Policy
Hospital Visitation Authorization
Informed Consent Form
Letter to Terminate Physician-Patient Relationship
Patient Contract Form
Patient Non-Discrimination Policies
Patient Visitation Policies (LGBT Community)
Physician Orders for Life Sustaining Treatment
Request for Crime-Victim Records (Other than Child-Abuse Victims)
Request for Medication to End My Life in a Humane and Dignified Manner/Form
Sensitive Diagnosis/Authorization for Release of Information
Transferable Physician Order for Life-Sustaining Treatment Policy
Wellness Program Informed Consent Form
Withdrawing and Withholding Life-Sustaining Treatment Policy

Patient Safety and Adverse Outcomes
Disclosure and Apology Workbook
Disclosure of Outcomes Policy
Investigation Data Collection Form for PL and Adverse Events
"Never Events"--Sample Contract Provisions
Unanticipated Outcome Policy

Physician Employment
Amendment to Physician Employment Agreement
Deferred Compensation Agreement
Hospital-Based Physician Group Exclusive Contract Negotiation Checklist
Hospital-Physician Incentive Fee Arrangements Checklist
Medical Director and On-Call Agreement
Medical Director Job Description
Medical Director/Hospital Agreement
Monthly Time Allocation Study
Physician Contract Checklist: Recruitment, Employment, and Independent Contractors
Physician Income Guarantee Monthly Report
Physician Pay Period Chart
Physician Recruitment Agreement
Physician Recruitment Compensation Checklist
Physician Supervision Agreement for an IDTF
Potential Physician Subsidy Recruitment Form
Professional Services Agreement Between a Medical Center and Physician
Time Study Report

Reimbursement
Certification of Financial Statements
Charge Master Neutrality--Sample Contract Provisions
Charity Care Policy and Application Guidelines
Collections Policy (Minnesota)
Conditions of Admission, Financial Responsibility, and Privacy Notice
Continued Stay Letter
Discount for Uninsured Patients
Eligibility for Provider-Based Status Checklist
Health System Charity Care and Financial Aid Guidelines
Hospital-Issued Notice of Noncoverage/Admission or Preadmission
Medicare Graduate Medical Education Affiliation Agreement
Medicare Law Toolkit
Medicare Members--Sample Contract Provisions
Medicare Part B Chart
Medicare Part C Chart
Medicare Part D Coverage Determination Request Form
Member Cost Share Contract Clauses
Memorandum of Understanding/Settlement Agreement
New Technology--Sample Contract Provisions
Overpayments and Recoupment Sample Correspondence
Request for Ambulance Transportation for a Beneficiary in a Medicare Part A Stay
SNF'S Notice to a Physician Treating a Beneficiary in a Medicare Part A Stay
Third-Party Billing and Prohibited Billing Practices Policy
Traditional Charity Care Worksheet
Unpaid Costs of Medicaid and Other Public Programs Worksheet
Voluntary Waiver of Medicare Benefits
Weekly Part A Beneficiary Service Log

Risk Management
Claims Management Oversight Committee Policy
Closed Claims--Sample Management Report
Contract Review and Execution Policy
Crisis Communications Plan Checklist
Crisis Communications Plan Contact List
Crisis Communications Plan Dos and Don'ts
Crisis Communications Plan Initial Press Statement
Crisis Communications Plan Media Inquiry Telephone/E-Mail Tracking Sheet
Development of a Physician Enterprise Model (PEM) Checklist
Director of Insurance Programs--Position Description
Health System Risk Management System
Open Claims--Sample Management Report
Policy on Policies
Preservation of Records for Legal Actions
Risk Management Committee Policy
Risk Management Program Policy--Hospital
Risk Management Program Policy--Medical Center
Vice President of Risk Management Job Description

American Health Lawyers Association (AHLA)

Leading health law to excellence through education, information, and dialogue, the American Health Lawyers Association (AHLA) is the nation's largest, nonpartisan, 501(c)(3) educational organization devoted to legal issues in the healthcare field. AHLA provides a wide variety of resources to address the issues faced by law firms, government, in-house counsel and academia and those who represent the entire spectrum of the health industry.