Forms
Which new patient forms are used only at state-line clinics?
Organization ApprovedSource Verified
Summary
Two additional forms are presented only at state-line clinics: the Patient Affidavit of Service of Notice of Medical Lien and the Irrevocable Provider/Patient Assignment. Both are signed and dated by the patient at the bottom.
- 1Patient Affidavit of Service of Notice of Medical Lien — present it with the approved script: "This acknowledges you are aware we will send you a copy of the lien we filed with the insurance company. Please sign and date at the bottom."
- 2Irrevocable Provider/Patient Assignment — present it with the approved script: "This acknowledges we will defer payment for your services until the claim settles. Please sign and date at the bottom."
- 3The Irrevocable Provider/Patient Assignment is the form used only in state-line clinics to acknowledge deferred payment until settlement.
- 4Add both forms to the new patient paperwork stack before the patient begins signing, so the flow is not interrupted.
- 5If a patient asks a question the script does not cover, do not interpret the document — refer the question to the doctor or a director.
Citation
CA Manual, New Patient Paperwork Scripts — State-line-only forms, p. 26–34 · Revised 2/9/26Answers source the CA Manual first; the Medisoft guide is used only where the CA Manual does not cover the task.