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A	Wisconsin Department of Regulation and Licensing Forms
Code	Description	Source	Cost
1	Wisconsin Chiropractic Board Forms	Board Website	N/C

2	Wisconsin Chiropractic Technicians (CT) Forms	Board Website	N/C

3	Wisconsin Chiropractic Radiological (CRT) Forms	Board Website	N/C

B	Website Contributor Forms
Code	Description	Source	Cost
DR0001	Assignment of Benefits ("Doctor's Liens")	Atty: Dan Riegleman	N/C

DR0002	Notice to Patient's Attorney/Thrid Party of Existence of Assignment of Benefits ("Doctor's Lien")	Atty: Dan Riegleman	N/C

DR0003	Letter to Patient whose Attorney Refuses to Acknowledge Assignment of Benefits ("Doctor's Lien")	Atty: Dan Riegleman	N/C

DR0004	Letter of Protection from Attorney/Third Party	Atty: Dan Riegleman	N/C

DR0005	Letter to Attorney/Third Party about Procedure to be Taken Following Settelment or Verdict with a Patient who Signed Assignment of Benefits Form ("Doctor's Lien")	Atty: Dan Riegleman	N/C

DR0006	Authorization for Release of Confidential Health Care Information ("Records Release")	Atty: Dan Riegleman	N/C

DR0007	Correspondence to a Party Requesting the Release of Health Care Information with Itemization of Information Required Before Release	Atty: Dan Riegleman	N/C

DR0008	Notice of Restrictions on Redisclosure of Health Care Records	Atty: Dan Riegleman	N/C

DR0009	Certification Form to Accompany Requested Health Care Recrords	Atty: Dan Riegleman	N/C

DR0010	Certification Form to Accompany Requested Health Care Bills	Atty: Dan Riegleman	N/C

DR0011	Office Policies and Procedures Information for Patients with an Injury Related Claim (Personal Injury/Worker's Compensation, etc.)	Atty: Dan Riegleman	N/C

DR0012	Notice to Patients of Options Available upon Insurance Companies Refusal to Pay a Claim	Atty: Dan Riegleman	N/C

DR0013	Assignment of Patient's Legal Interests to Doctor in Order to Pursue Claim/Litigation Against an Insurer or Other Third Party	Atty: Dan Riegleman	N/C

DR0014	Patient's Release/Indemnification of all Claims and Covenant not to Sue Doctor	Atty: Dan Riegleman	N/C

DR0015	Sample Language for a Lawsuit Against Patient to Recover Unpaid Treatment Charges	Atty: Dan Riegleman	N/C

DR0016	General Payment Plan or Agreement with Patient	Atty: Dan Riegleman	N/C

DR0017	Doctor's Notification to Patient of the Transfer of Their File to Another Office or Location	Atty: Dan Riegleman	N/C

DR0018	Request Form to Attorney on Status of a Patient's Case or Claim	Atty: Dan Riegleman	N/C

DR0019	Doctor's Letter to Patient's Attorney Seeking Patient Records or Narrative Report on Required Costs/Prepayment	Atty: Dan Riegleman	N/C

DR0020	Doctor's Letter to Patient's Attorney Seeking Deposition or Trial Testimony on Required Costs/Prepayment	Atty: Dan Riegleman	N/C

DR0021	Notice to Patient of Doctor's Dicontinuance/Termination of Chiropractic Treatment	Atty: Dan Riegleman	N/C

DR0022	Notice to Another Physician on Referral of Active Patient Care Pursuant to Wis. Stats. §446.02(7d)	Atty: Dan Riegleman	N/C

DR0023	Sample Informed Consent Language	Atty: Dan Riegleman	N/C

DR0024	Finiancial Hardship Agreement - Waiver of Co-Payments, Deductibles, or Non-Insurance Patient Situation	Atty: Dan Riegleman	N/C

DR0025	Voluntary Patient Financial Information Form Necssary to Qualify Patient for Waiver of Co-Payments, Co-Insurance, and Deductibles	Atty: Dan Riegleman	N/C

DR0026	Notice to Insurer of Waiver of Patient's Co-Payments, Co-Insurance or Deductible, Pursuant to Wis. Stats. §446.0210)	Atty: Dan Riegleman	N/C

DR0027	Patient Consent to Treatment Form and Financial Agreement on Payment for Services (Non-Personal Injury or Workers Compensation Patient)	Atty: Dan Riegleman	N/C

DR0028	Letter to Workers Compensation Insurer or Self-Insurer Justifying Disputed Patient Fees and Providing Notice of Potential Submission of Dispute Process within the Department of Workforce Development	Atty: Dan Riegleman	N/C

DR0029	Letter to Workers Compensation Insurer or Self-Insurer Justifying Disputed Patient Reasonables of Care Provided Patient and Providing Notice of Potential Submission of Dispute Process within the Department of Workforce Development	Atty: Dan Riegleman	N/C