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Home > MEDICAL / CHIROPRACTIC > Medical Forms > HIPAA Forms >

Custom Privacy Patient Sign-In

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List Price: $245.00

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Unit Qty: 100
Unit: pack
Overall Dimensions: 8-1/2" W x 11"

Product Code: C-PS-DM-1P

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Order 1 - 2 Boxes or Packs Shipping Cost is $19.95
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Description

Freight, Returns & Sales Tax Policies

The ACS NEW Custom Patient Sign-in Log / HIPAA Compliant

Your Company Information & Logo.
Customize Your Own Columns.
1 part
Printed in Black Ink.
20 sign in positions on each sheet.
Sheets are 8-1/2” x 11”.
Price includes set up costs.
Shipping is a flat $9.95 for 200 or less, anything from 300 up is free shipping.
Ships in 5 working days on approval of proof.

After you place your order, you will be contacted for your design and imprint info. Then you will receive an email or fax proof of your design before we go to press with your order. This gives you a chance to make any last minute changes before it's printed.

How it works:

1. Keeps patient visits private
Each patient completes the form's top line - a self-adhesive strip that includes a removable
number to give to patients if you wish to call them by number instead of name.

2. Updates the chart
Before the next patient signs in, the receptionist removes the strip and places it either on a
call sheet or into the chart. The completed label alerts you to changes in patient information.

3. Protects confidentiality
The label liner keeps the duplicate record hidden from patients that follow. Once the form is
completed, detach the edges (which discourage peeking) to discard the liner and release the log.

4. Verifies billing and keeps an audit trail
The Patient Sign-In log automatically creates a duplicate record sheet of every appointment, which you can file away or store in a binder. This log also helps you analyze wait times and better manage patient volume and flow.

FREIGHT CHARGES
ACS always confirms to our customers total amount to be charged including freight costs before order
is processed.

RETURNS
There is a 15 day return policy. Customers have 15 days to return products after they have received them. Products are not returnable after this time. Returns are subject to a restocking fee of 25%. If the return is a result of our error, we will issue a call tag. We grant returns on products only if the product and the packaging are in re-sellable condition. Custom products are not returnable.

SALES TAX
ACS charges sales tax if you are a Texas resident, Texas State Sales Tax will be added at the time your
order is invoiced. If you are tax exempt you must provide a Texas Sales Tax Exemption Certificate.

Colors & Features

You can have your Facility imprint, Doctors names, and (or) custom fields for patients to sign-in on. Below are just examples to serve as idea starters of what is possible. Contact us and we can help you customize your form.

Facility Name centered, Facility Address in top left, Participating Doctors in top right,custom sign-in fields. This form for a Pediatric office includes a blank for "Parent Name".

Facility Name centered, custom sign-in fields. This form for an Ob/Gyn office includes checkboxes for "New Patient" and "Changes since last visit".
Simple title of Form centered, Doctor Name in top left, Facility Address in top right, custom sign-in fields. General sign-in sheet template.
Facility Name centered, custom sign-in fields. This Radiology office example can have text added to the top right and left corners of the page.
Simple title of Form centered, Facility Name & Address in top left, Participating Doctors in top right, custom sign-in fields. General sign-in sheet template.
Facility Name centered, custom sign-in fields. This Internal Medicine office
example includes "Name", "Date", "Time Arrived", "Time of Appointment" and "Doctor".