Policies and Forms

Privacy Practice Form

DOT Forms

Medical Examination Report Form with Instructions
Medical Examiner's Certificate



1001. By-Laws
1002. Governing Body Conflict of Interest
1003. Policy Development and Approval


2001. Affirmative Action
2002. Compliance Plan
2004 - Dismissal from Care
2004 - Procedure - Disruptive Patient Using Physical or Verbal Threats
2004 - Procedure - Dismissal from Care
2005. HIPAA Security Plan
2006. Liability Insurance Coverage
2007. Medical Records Confidentiality Policy
2008. Misappropriation of Funds - Irregular Practices
2009. Patient Grievances
2010. Patient Request to Amend Medical Record
2011. Patient Rights and Responsibilities
2012. Patient Satisfaction Surveys
2015. Property and Equipment Security
2016. Records Retention
2017. Red Flag Policy
2018. Risk Management Plan
2019. Scheduling Appointments
2020. Standards of Conduct
2021. Treatment of Minors
2022. Whistle Blower Policy
2023. Providing Meaningful Communication with Persons with Limited English Proficiency


3001. Appropriate Supervision and Backup of Clinical Staff
3002. Chronic Pain Management
3004. Credentialing Process
3006. Donated Pharmaceuticals
3008. Drugs and Biologicals
3010. Hours of Operation
3011. Immunizations
3012. Incident Report - Sentinel Events
3013. Informed Consent
3014. Laboratory
3016. Medical Chart Audits and Peer Review
3017. Medical Records
3018. Outdated Medication
3019. Patient Medication Contracts
3020. Patient Services
3022. Policy and Procedure Manual - Medical/Dental
3023. Quality Improvement Plan
3024. Referral Assistance Program
3025. Follow-up/Internal Tracking/Referral
3026. Transport of Patients
3027. Triage of Walk-in and Telephone Patients
3028. Victims of Abuse or Neglect
3029. Directors Compliance Committee Policy
3030. Death Certificates
3032. Cancellation No Show and Late Arrival
3033. Medication Reconciliation after Transition of Care
3034. Afterhours Coverage


4001. Allowance for Contractual Adjustment
4002. Sliding Fee Scale
4003. Draw Down Policy
4004. Budget Planning and Control
4007. Procurement Policy
4008. Donations and In Kind Contribution
4009. General Financial Policies and Procedures
4010. Independent Financial Audits
4012. Monthly Journal Entry Review
4013. Outstanding Check Policy
4014. Patient Registration and Sliding Fee Scale Eligibility
4015. Payroll
4016. Receipts and Collections
4017. Reduction in Fees
4023. Internal Controls
4025. Inventory Control Management
4026. Billing, Payment Options and Collections
4027. Investment Policy


5001. Data Back Up
5002. Data Security
5003. Email and Internet Usage
5004.  Access Controls For Protected Health Information
5005. Antivirus 
5006. Notification of Breach of Unsecured Protected Health Information
5007.  Privacy
5008. Visitor 
5009. Configuration Management
5010. Information Systems Change Control
5011. Facility Maintenance Records
5012. HIPAA Privacy and Security Training
5013. Information System Activity Training
5014. Information Systems Equipment and PHI Inventory
5015. Limited Data Set
5016. Notice of Privacy Practices
5017. Password Management 
5018. Software Patch Management
5019. Patient Photos in the Medical Record
5020. Security Incident Response
5021. Sanctions for Inappropriate Release of Protected Health Information
5022. Security Risk Assessment for Information Technology
5023. Systems and Communication Protections 
5024. Remote Access


SUD001. Co-Occuring Clients and Services
SUD002. Medical Marijuana
SUD003. Outpatient Therapy
SUD005. Pregnant Women and Women with Dependent Children
SUD006. Special Population Priorities
SUD007. TB HIV AIDS Hep B and C
SUD008. Intravenous Drug Use
SUD009. ACT Program
SUD012. Minor in Possession (MIP) Program


BH002. Waiting List
BH004. Medication Management Services
BH005. Independence of Intensive Case Manager and Intensive Case Management Program  
BH006. Behavioral Health Student Internships
BH007. Continued Stay Reviews


6003. Disciplinary Measures
6004. Drug Free Workplace
6005. Employee Orientation
6006. Employee Records and Inquiries
6007. Employee Standards of Conduct
6008. Leave and Holiday Benefits
6010. Employment Status
6011. Equal Employment Opportunity
6012. Grievance Procedures
6012A. Employee Grievance Acknowledgement Form
6013. Health Insurance
6014. Payroll Procedure
6015. Performance Management Plan
6016. Retirement Plan
6017. Termination of Employment
6018. Training Time and Expense
6019. Wage and Salary Administration
6020. Continuing Education Policy
6021. Employment of Relative
6022. Protection from Litigation
6023. Recruitment and Retention
6025. Children in the Workplace
6027. Background Check Policy
6029. Dress Code Policy
6030. NonDiscrimination/Anti-Harassment Policy and Complaint Procedure
6031. Lobbying and Political Campaign Activities 

6032. Use of Company Vehicles and Equipment
6033. Recruiment and Retention for C-Suite
6034. CEO Succession Policy
6035. Incentive Pay during Emergency or Extraordinary Circumstances

Personnel Handbook


7000. Bullhook Community Health Center Emergency Plan
7001. Disaster Prep and Response

7002. Emergency Care Policies Binder
7003. Emergency Preparedness Plan
7004. Exposure Control Plan
7005. Facility Maintenance Plan
7007. Hazardous Materials and Waste Management Plan
7008. Infection Control
7010. Occupational Health and Safety Plan - OHSA Forms for Recording - Work-Related Injuries and Illnesses
7014. Workplace Violence Prevention
7015. Business Continuity Plan
7016. Communicable Disease
7017. Patient Tracking
7018. Shelter-in-Place
7019. Telephone Disaster
7020. Power Outage
7021. Emergency Preparedness Human Resources
7022. Employee Immunizations


DEN 001. Basic Guidelines for Treatment
DEN 003. Practice Policy Introduction
DEN 004. Categorization of Services
DEN 005. New Patient Appointment Policy
DEN 006. Recall Appointment Policy
DEN 007. Emergency Appointment Policy
DEN 009. Consent for Treatment
DEN 011. Referral and Follow-up Policy
DEN 012. Quality Assurance and Chart Auditing
DEN 015. Infection Control, Sterilization and Disinfection
DEN 016. Medical Emergencies
DEN 018. Prescribing Medications
DEN 021. Radiation Control Policy
DEN 023. Patient Scheduling/Patient Flow
DEN 026. Patient Tracking/Clinic Productivity Measures
DEN 037. Level I Dental Services
DEN 038. Level II Dental Services
DEN 039. Level III Dental Services
DEN 040. Level IV Dental Services


8001. Goals and Objectives of the Pharmacy Department
8002. Legal Aspects
8006. Eligibility for Pharmacy Services
8007. Handling Fee Charge for In-House Pharmacy
8010. Controlled Substances
8011. Storage of Drugs
8012. Pharmacy Security
8013. Patient Profiles
8014. Dispensing Prescriptions
8015. Prescription Drug Quantity and Days Supply
8016. Medication Labeling
8017. Records of Dispensing
8018. Distribution of Pharmacy Stock to Clinic
8019. Personnel Training
8020. Personnel Training Record
8021. Perpetual Inventory Record Keeping
8022. Pharmacy Monthly Report
8024. Pharmacy Cleaning Policy
8025. Patients Altering Written Prescriptions
8026. Adverse Drug Event
8027. Regulatory Inspections
8035. Filling Prescription for Providers under Investigation or on the Office of Inspector General's List
8036. Verification and Handling of Suspect or Illegitimate Product
8037. Intent of 340B Program
8038. 340B Medication Program Compliance
8039. Anti-Kickback Statute
8040. Drug Supply Chain Security Act
8041. Pharmacy Freedom of Choice
8042. 340b Training
8043. Establishing Material Breach Threshold 340B Program Compliance


APPENDIX A Informed Consent Forms
Informed Consent for Endodontic (Root Canal) Treatment
Informed Consent for Oral Surgery (Tooth Extraction including Wisdom Teeth)
Informed Consent for Oral Surgery for Patients using Bisphosphanate Medications
Informed Consent for Restorative Treatment
Informed Consent for Scaling and Root Planing (Deep Cleaning)
Informed Consent for Dental Prophylaxis
Informed Consent for Administration of Nitrous Oxide
Patient Consent Form


Dental Laboratory Procedure
Determining Willingness to Pay Procedure
Disruptive Patient using Physical or Verbal Threats Procedure