Practice Policy Templates

These policy templates are provided as a reference for practices developing their own materials and may be adapted to local needs. You should consult an attorney who is knowledgeable about the laws of the jurisdiction in which you practice before creating or using any legal documents. ​

​Disclaimer: These sample documents do not represent AAP policy or guidelines. They are provided only as a reference for practices developing their own documentation.

​ Patient Policies

Financial Policy Samples

These sample financial policies can be used and/or adapted to meet the needs of your practice.

• Watchung Pediatrics Office Financial Policy​​ (New Jersey)
• Village Pediatrics, LLC Office Policy (Connecticut)
• Tamalpais Pediatrics Financial Policy (California)
• Eden Park Pediatrics Office Financial Policy ​ (Pennsylvania) ​​​

Appointment Policy Sample – Sample policy to share with families about appointments, including no-show fees, late arrivals and making appointments.

Practice Policies and Procedures Templates

Appointments/Scheduling

• Monitoring of Appointment Needs and Preferences – Template policy and procedure on how the practice obtains and monitors patient and family feedback on appointment needs.
• Access Improvement for Appointments – Template policy on appointment access and procedure for regular monitoring of access data.
• Appointment Availability – Template policy and procedure to effectively triage patients and ensure appropriate appointment scheduling.
• Arrangement of Alternative Appointments – Policy and procedure on scheduling alternative (eg. telehealth) visits.
• Extended Hours of Care – Practice policy outlining operating business hours of the practice.
• Secure Electronic System for Appointment, Referral and Test Result Requests – Policy and procedure on responses to patient/family inquiries received via patient portal or e-mail.

Office Workflow

• Team Huddles and Meetings – Policy and procedure on team huddles and staff meetings.
• Tests: Ordering, Tracking, and Reporting Policy – Policy and procedure around ordering and tracking tests performed both inside and outside of the practice.
• External Diagnostic Test Tracking and Notification Policy – Policy and procedure around tracking and follow-up of tests conducted outside of the practice.

Care Coordination

• Coordination of Care with an ER or Inpatient Setting – Policy and procedure to identify and provide appropriate follow-up to patients who have been hospitalized or seen in the hospital system.
• Continuity of Care/Exchange of Patient Information/Obtaining Discharge Summaries – Policy and procedure for communicating with other health care facilities to exchange information.
• Referral Tracking – Policy and procedure for tracking referrals to subspecialists and subspecialist reports received.

Clinical/Population Health

• Identifying High Risk Patients – Policy and procedure to identify and contact high risk patients who may benefit from care management.
• Depression Screening – Policy and procedure for identifying and managing patients who may be depressed.
• Advanced Directives – Policy and procedure around advanced care planning.

Other

• Handling Patient/Family Complaints/Grievances: Policy for communicating with patients/families who express dissatisfaction or a grievance.