Forms
How do I submit a check request or log a referral gift card?
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Summary
The Lien/Police Report Check Request Form is used when checks run low, the Check Request Form covers any other expense, and referral gift cards are tracked on the Patient Referral Gift Card Log.
- 1Only the Clinic Director submits the Lien/Police Report Check Request Form, once down to one week's worth of checks; liens and police reports each require a separate form and must not be combined.
- 2Fill in the clinic name, mark whether the checks are for liens OR police reports, and note the average number of checks used per week.
- 3Count all checks on hand (lien or police report, not both), indicate to whom checks should be made payable, print the Clinic Director's name, sign and date, then email the form to the Management Office.
- 4Use the Check Request Form to request a check for any purpose other than petty cash, liens, or police reports; only the Clinic Director completes it and submits it to the Management Office with an invoice or receipt.
- 5When a patient refers another patient, add the referral to the Patient Referral Gift Card Log.
- 6Once the referred patient has had three visits with charges and a lien has been recorded in Medisoft, the Clinic Director uses the Check Request Form to purchase a gift card.
- 7The Clinic Director lists the gift card number on the log and places the card in the Petty Cash box until the patient picks it up.
- 8When the patient arrives, obtain the card from the Clinic Director, have the patient sign the log, and initial as the CA confirming the card was given.
Citation
CA Manual, Lien/Police Report Check Request Form; Check Request Form; Patient Referral Gift Card Log, p. Miscellaneous · Revised 2/9/26Answers source the CA Manual first; the Medisoft guide is used only where the CA Manual does not cover the task.