ExecTech Client - Legal Questionnaire

The purpose of this checklist is to help you find and prevent legal problems before they can hurt you or your practice.

While no list can cover every possible legal risk you face, this checklist includes most common legal problems experienced by practice owners.

If you are currently involved in a legal action (lawsuit, government investigation, etc.), ExecTech should not get involved. However, if you do not have an attorney, or feel your attorney is not handling the situation as well as you like, we may be able to refer you to a more competent attorney.

You can scroll to the bottom of the form and save your progress to continue later if you are not able to complete in one sitting.

Name*

First NameLast Name

Practice Name*

General Questions

1. Business Taxes. Are you concerned if you are properly paying your business taxes, sales taxes, payroll taxes or business property taxes?

MaybeNo

2. Taxes Audit Protection. Do you have a tax expert who will represent you in an audit?

YesNo

3. New Patient Arrangements. Do you have any questions or concerns about marketing activities that may be inappropriate?

PossiblyNo

4. Office Safety. Do you have any questions or concerns regarding your OSHA requirements?

YesNo

5. Unprofessional Conduct. Do you have any questions or concerns regarding activities that might be construed as unprofessional conduct?

YesPossiblyNo

6. HIPAA Privacy Rule. Do you have any questions or concerns regarding the HIPAA Privacy Rule?

7. Pending Issues. Do you have any concerns regarding the competency of your legal counsel?

YesNo

8. Drugs. Do you have any questions or concerns regarding the handling, dispensing or prescribing of drugs by your practice?

YesNo

9. Advertising. Do you have any questions or concerns regarding the laws for advertising?

YesNo

10. Contracts. Do you have any questions or concerns regarding a contract you have signed or should have signed?

YesNo

11. Partnership Agreement. Are you in a partnership arrangement without a written agreement?

Not applicableYesNo

Patient Care

12. Malpractice Insurance. Do you have any questions or concerns regarding your professional liability insurance coverage?

YesNo

13. Malpractice Insurance Restrictions. Do you have any questions or concerns regarding your policy, such as what you can or cannot do?

YesNo

14. Associate/Partner Malpractice Insurance. Do you have any questions or concerns regarding malpractice protection for your associate’s or partner’s acts?

YesNo

15. Former Associate/Partner Malpractice Insurance. Do you have any questions or concerns regarding a leaving or former associate’s or partner’s coverage?

Yes, I have questionsNo problem

17. If you have informed consent forms, has your malpractice insurance carrier approved the wording?

YesNoDo not use informed consent forms

18. Informed Refusal. Do you have any questions or concerns regarding a patient who refuses to follow your recommendations?

Yes, I have questionsNo

19. If you have informed refusal forms, has your malpractice insurance carrier approved the wording?

YesNoDo not use informed refusal forms

20. Documentation. Do you have any questions, weaknesses or concerns regarding your office’s proper documentation of each patient’s care?

YesNo

21. Files. Are your patient records in excellent condition?

YesNot sure

22. Sexual Harassment. Do you have any concerns or questions about patient sexual harassment?

YesNo

23. Patient Dismissal. Do you know how to dismiss patients in a safe and legal manner?

YesNo

24. Patient Complaints. Do you have any questions or concerns regarding current or former patients who may possibly be unhappy with your treatment?

YesNo

25. Complaint System. Do you have any questions, weaknesses or concerns regarding a system to catch and resolve patient complaints before they escalate?

YesNo

26. Emergencies. Do you have any questions regarding patient emergencies that can arise during treatment in your practice?

YesNo

Fees and Collections

27. Fees. Do you have any questions or concerns about the law regarding fees?

YesNo

28. Fee Arrangements. Do you have any questions or concerns about fee splitting or fee fixing?

YesNo

29. Third-party Collections. Do you have any concerns about the legalities of collecting from third-party payers?

YesNo

30. Patient Collections. Any questions or concerns regarding the legalities for collecting from patients?

YesNo

31. Insurance Fraud. Any questions or concerns about coding, billing, fraud and so on?

YesNo

32. Insurance Company Conflicts. Do you have any questions or concerns that you might become involved in a legal conflict with an insurance company?

YesNo

33. Advance Pay Packages. Do you discount your fees for patients who pay for packages of care in advance?

YesNoNot applicable

34. If you offer such discounts, do you have patients sign an Advance Pay Agreement?

YesNo

35. Hardship Patients. When you give discounts to hardship patients, do you have them sign an agreement?

YesNoDo not give hardship discounts

Labor Law

36. Job Application. Does your job application cover your legal bases? (Click the yellow questionnaire mark for details.)

YesNo

37. Employment Agreement. Do you have a written agreement with all your employees?

YesNo

38. Associate Agreement. Do you have a written associate agreement with your associate doctor(s)?

YesNoI have no associate

39. Sub-contractors or Independent Contractors (same thing). Does anyone work for you on a sub-contractor arrangement?

YesMaybeNo

40. If so, do you have a written sub-contract agreement with this person or persons?

YesNo

41. Office Policy/Employee Manual/Staff Handbook (same things). Do you have a written office policy/employee manual/staff handbook?

YesNo

42. If you have an office policy or staff handbook, has a labor attorney written or reviewed it?

YesNoNot Applicable

43. If you have a policy or handbook, have all your staff members signed agreements that they have received and understand the policy?

YesMostlyNoNot Applicable

44. Exempt Employees. Do you classify any of your staff members as exempt employees and pay them a salary without overtime pay?

YesNoNot sure

45. Overtime Pay. Do you have any questions or concerns regarding overtime pay?

YesNo

46. Workers' Compensation Insurance. Do you have any questions or concerns regarding your work comp insurance coverage for your employees?

YesNo

47. Personnel Files. Do you keep a complete employment file on each employee

YesSort ofNo

47. Personnel Files. Do you keep a complete employment file on each employee

YesSort ofNo

48. Staff Complaints. Do you have a system in place to catch and resolve staff member complaints before they escalate into legal matters?

YesNot sure

49. Staff Relations. Do you have any questions or concerns regarding any of your current or past employees who might file a complaint or claim against you?

YesNo

50. Licensing. Do you have any questions or concerns regarding the delegation of technical duties to staff?

YesNo

Personal Issues

51. Past Connections. Are you concerned anyone from your past might want to hurt you or your practice (i.e., ex-spouse, former partner, former employee)?

SomehwatNo

52. Asset Protection. Do you have any questions or concerns regarding your legal asset protection plan or do you need such a plan?

YesNo

53. Last Will and Testament. Do you have a current will?

YesYes, but it needs updatingNo; I would like oneNo; I am not concerned

54. Living Will. Do you have a living will?

YesNo; I would like oneNo; I am not concerned

55. Estate Plan. Do you have an estate plan?

YesNo; I would like oneNo; I am not concerned

56. Insurance. Do you have adequate life and disability insurance?

YesNot sureNo; I should arrange moreNo; I am not concerned

57. Death and Disability Practice Plan: Do you have a written plan for your practice should you die or become incapacitated?

YesNo; I would like oneNo; I am not concerned

58. Final. Do you have any legal questions or concerns not covered by this questionnaire?

YesNo

Thank you! Please submit.