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Closing A Practice Guide

This document provides a checklist for closing a psychiatric practice. It includes designating a special administrator to handle closing affairs and notifying staff and patients. It also lists where active and terminated patient records are kept, contact information for state medical boards and affiliations, and details on financial, billing and business records and accounts.

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Agnes Margarita Santiago
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75 views9 pages

Closing A Practice Guide

This document provides a checklist for closing a psychiatric practice. It includes designating a special administrator to handle closing affairs and notifying staff and patients. It also lists where active and terminated patient records are kept, contact information for state medical boards and affiliations, and details on financial, billing and business records and accounts.

Uploaded by

Agnes Margarita Santiago
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Appendix A

Emergency Closing Check List

1. Special Administrator
Person authorized as responsible for practice affairs, and can access
necessary keys and passwords for business records

I designate the following person as my Special Administrator to handle


the closing of my practice:

Name: Telephone:

2. Staff:
Staff should be notified as soon as possible to ensure that patients are
notified in a caring, supportive, and professional manner.

Name: Telephone:

Name: Telephone:

Name: Telephone:

Name: Telephone:

3. Patients
By having the following information readily available, the staff will be able
to generate letters to inform patients of the practice closing and identify
colleagues who will be able to assist your patents. Appendix B has
sample letters that can be used for this purpose.

A. My Active list (Name, address, and telephone number) of Patients is


kept:
Electronic Version - File Name and Directory Information:

________________________________________________________

Hard Copy Version - File Name and File Cabinet Drawer:

________________________________________________________

My Active Patient records are kept:

________________________________________________________

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B. My Terminated List (Name, address, and telephone number) of
Patients for whom I still hold records for is located:

Electronic Version - File Name and Directory Information:

________________________________________________________

Hard Copy Version - File Name and File Cabinet Drawer:

My terminated records are located:

4. Patient Issues

A. Coverage - Emergency/Prescriptions/Patient Transfer

Dr. ___________________________ at telephone number:


___________________ has agreed to handle the emergency and
prescription needs of my patients on a short-term basis.

B. Coverage - Colleagues to assist my Patients in finding another


psychiatrist:

Name: Telephone:

Name: Telephone:

Name: Telephone:

Name: Telephone:

C. Patient Appointments
My appointments are arranged by:

____Me ____Staff _____Others

My actual patient schedule is located:


_______________________________________

21
5. State Medical Board(s)

The telephone number(s) for the state medical board(s) where I am


licensed to practice medicine is/are: ______________________,---------------
----,--------------------.

My license number(s) is/are: ______________________________________

My license(s) expire on: __________________________________

6. DEA Notification

The Federal DEA office Contact Information is:

Telephone Number: __________________________________

My DEA Certificate Number is: _______________________

The local DEA Office contact information is:

Telephone Number: __________________________________

The Department of Public Health Contact Information is:


Telephone Number: __________________________________

7. Medication Storage
I keep medications in my office: Yes____ No____

If yes: where_________________________________

I keep Controlled Medications in my office: Yes_____ No____

If yes: where_________________________________

8. Prescription Blanks

My Prescription Blanks are kept: ______________________________________

My Triplicate Prescription Blanks [if relevant] are kept:


____________________________

22
9. Hospital/Clinic Affiliations

I am affiliated with the following Hospitals/Clinics:

Name: Telephone:

Name: Telephone:

Name: Telephone:

Name: Telephone:

10. Third Party Payers


I am currently on panels for the following Payers:

Name: Telephone:

Name: Telephone:

Name: Telephone:

Name: Telephone:

11. Billing
My billing is handled by:

___Me ____Staff ________Billing Service

The staff person who coordinates my billing is:


_______________________________________

My Billing Service is: _________________________________.

Telephone Number: _______________________

23
12. Location of Business Records/Bills:

Copies of my business records are kept ______________________________

____________________________________________________________________________

13. Business Accounts and Contact Information

(Not all these services will apply to your practice: Amend Template to suit your practice)
Service Company Name Account # Contact Name Contact #
Provider
Business
Phone

Business Cell
Phone

Business Fax

Internet
Provider

Copier

Computer

Office
Supplies

24
Service Company Name Account # Contact Name Contact #
Provider
Premises
Lease

Insurance
Agent
(Property/Life
Workers
Comp/
Disability etc.)

Attorney

Medical
Malpractice
Insurance
Carrier

Electricity
Supply

Oil/Gas
Supply

Water Supply

25
14. Financial Records

a. ________________________ is a second signatory on my checking account.

b. The following is a listing of all my financial information for my practice

Service Company Name Account # Contact Name Contact #


Provider
Practice Bank
Account

Financial
Advisor
(Investments/
Retirement)

Practice
Accountant

Payroll Service

26
15. Professional Contacts/Associations

The following associations should be contacted to terminate my membership/affiliation.


Company or Membership # Contact Tel # Comments
Activity Personal Contact or
Name Account #
Professional
Association(s)
Specialty
Boards, e.g.,
ABPN
Journal(s)/
Subscription(s)

Supervision
Responsibilities

Teaching
Responsibilities

Other Regular
Clinical
Commitments

Other Regular
Professional
Commitments

27
Appendix A – Sample Patient Record Disposition Worksheet

Patient List of Dr: ___________________________________________

Patient Name Date of Treatment Treatment Primary Date Comments


Birth From: To: Diagnosis Record
Destroyed

28

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