Letters
Anal Wart Letter
Back Pain & Hemorrhoids
Colon Adenoma Letter
Confirmation of Consult
Greater than Usual Svc Letter

Info 4 Anesthesia Svcs (pdf)
Motility Study Referral Letter
Thank You Letter to Doctors
Thank You Letter to Patients
Yearly Recall Letter

Consents
Surgical Procedures (pdf) 2-22

Interferon Informed (pdf)
Pilonidal Cyst

Proctology (pdf) 1-7-17

Proctology/Endoscopy
Upper Endoscopy
Conscious Sedation & Procedures Consent (pdf)

Copyright © Top Rate Doctors

CPT Coding Rules

GotNPI.com: CPT Prices & Correct Coding Initiatives (CCI) Edits

Medicare Published "NCCI Procedure to Procedure (PTP) Edits" for Coding
ICD-10 Lookup

ICD-9 to ICD 10 Cross Coder
CMS Local Carrier Determination (LCD) Policy Lookup Alphabetically

Medicare Payment Lookup

Medicare Payment Settings

Colorectal & Anal CPT Codes

CMS Global Surgery Period Booklet

Modifier-reference-guide Anorectal Wall Biopsy & Modifiers

Modifier -25

Price List Proctology Coviden

Reports
Anesthesia Note
Colonoscopy Note
Decision Making
Eval & Mgt Guide CMS
Eval & Mgt Guide Summary
History & Physical Form
History & Physical Report
Progress Note

New Packaged Forms
Office Treatment 6-18

Minor Surgery Post-op

Minor Surgery Pre-op 3-23

Rx Intron A Package (signed)

Major Surgery 10-23

Miralax Packet 3-17

Registration 10-23

BILLING

Master Superbill (pdf) 11-2023

Dermatology Superbill

Post Operative Instructions
Anal Dilators
Banding
Colonoscopy
Diet After Surgery
Infra Red Coagulation
Pilonidal Cyst
Rectal Office Surgery
Rectal Surgery
Upper Endoscopy

What To Expect After Skin Lesion Surgery (pdf)

Skin Suture Surgery (pdf)

What To Expect After Rectal Surgery

Patient Handouts
Exparel® - Non-opioid Analgesia

Hotels Near the Office (pdf)

Pap Screening Guidelines

Pearly Penile Papules PPP

Hypertensive Crisis

Analgesia for the Breastfeeding Mother

Anal Dilation Therapy

OLD SUPERBILLS

Proctology - 2015

Genital Warts Center - 2015

OFFICE VISITS

New Visit (pdf) 2-20-22

FollowUp Visit (pdf) 2-20-22

FollowUp Visit Upgrade: 99215 (pdf)

Conscious Sedation Consent & Documentation 3-24

CS Consent (pdf) CS Documentation (pdf) 3-24

Medical Assistant Services (pdf)

Proctology Procedure Explanation Checklist (pdf)

Exparel® - Long-lasting Non-opioid Analgesia

ABN for Compounded Medicine

EuroMed

PA Supervising Agreement (pdf)

- (Ivette.pdf)

Supervising Physician Rules

Homeopathic administrative code

Room Preparation Instructions

Exparel

Financial Information

ABN Mecicare

ABN Federal (pfd)
Attorney Lien
Federal Waiver
Financial Hardship
Refund & Liability Release

Intron A Prior Auth(signed)

REFERRALS
Tri-City

McConnell

McClary (pdf)

Verma (pdf)

Kahn (pdf)

SWCN Medical Center (pdf)

Surgical Center of Scottsdale

Scheduling Slip

Out of Pocket Letter (pdf)

Place Of Service
Abrazo Central Campus

Warner Park Surgery Center

Place Of Service
Abrarzo Scheduling

Warner Park Scheduling

Practice Guidelines

Hypertensive Crisis Mgt

Bupivicaine Max Dosage

HSIL AIN Comparison

Patient Positioning Sheet

Tirzepatide Clinic
- Marketing/Practice info -

BMI Chart

Weight Loss Screening & Price (pdf)

Weight Loss Regist Pkt

TIRZ Dose Guide 20mg (pdf)

TIRZ Dose Guide 10mg (pdf)

Zepbound Dose Guide (pdf)

Semaglutide Dose Guide (pdf)

Rx Zepbound

Diet Tips (pdf) 3-17-24

- print for every patient chart -

ABN for Tirzepatide

ABN for Zepbound/Mounjaro

WL MEDICATION LOG (pdf)

New Pt WL (pdf) 2-24

FollowUp Pt WL (pdf) 2-24

- archived forms -

Consent Tirz (pdf)

Eating Dis Consent (pdf)

APA Guide Eating Dis

Excluded Injectable Meds List

Indications 4 Binge Eating Rx

Strive Semaglutide Tx Protocol

Strive Tirzepatide Tx Protocol

Miscellaneous
Anal Hygiene
Anti-Itch

Atkins Diet (pdf)

Carbohydrate Counter

Cotton Roll Rx
Fodmap Diet
High Fiber Diet
Kegel Exercises
Perfecto Recto Award

Hospital Orders

Pilonidal Cyst Orders
Rectal Surgery Orders

Home Health

Nursing Pilonidal Orders
Nursing Proctology Orders
Pharmacy Pilonidal HH
Pharmacy Surgery HH

Hospital Forms

Colonoscopy report

EGD Report

Operative Report

Fistula Plug Instructions

Rx Pilonidal Pkg (pdf)

ECCO

Nitrous Oxide Consent (pdf)

Policy
Appointment Policy

Appointment Confirmations

BCBS Clinic Policy - Assignment of Benefits

Hosp Communications
Place - Warner Park (pdf)
Place - Abrazo Central (pdf)
Surgery Prescription Slip

Registration
Clinical Policies (pdf)

Demographics Patient Info (pdf)
Informed Consents (below)
Notice of Privacy Policies (pdf) 1-17
Pt Communication Auth (pdf) 8-22
Patient Questionnaire 10-22
Registration Packet (See above)

CONTACT DR. SHACKET

Five Points Health Center

Ad
Brochure
Clinic Policy
MMJ ID Cards
History & Physical Form (pdf)
Letter to Primary Care Physician
Medical Records Release
Medical Records Statement
Physician Certification of an Adult
Physician Certification of a Minor
Progress Note
Registration Package

Credentialing

Proctology Name Change to

Colon & Rectal Surgery

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TOP RATE

DOCTORS & CLINICS

Old Packaged Forms
NuLytely/TriLyte Paket 3-17

OsmoPrep Packet
Surgery Full Packet
Surgery Light Hospital
Surgery Light Office
Surgery + Miralax
Surgery + Nulytely/TriLyte
Surgery + OsmoPrep

Suprep Packet

Communications
Medical Records Release (pdf)
Work & School Excuse (pdf)

Postoperative Questionnaire (pdf)

Preoperative Preparation

Fasting & Clean-out (pdf)
Avoid These Drugs (pdf)
Colonoscopy – Miralax
Colonoscopy – NuLytely/TriLyte
Colonoscopy – OsmoPrep
Flexible Sigmoidoscopy
Rectal Surgery – Hospital
Rectal Surgery – Office

Suprep Instructions (pdf)

Prescriptions
Rx Acyclovir (pdf)
Rx Anoheal (pdf) 6-19
Rx Ambien (pdf)
Rx Amitiza
Rx Analpram HC (pdf) 8-17

Rx Apriso (pdf)

Rx Asacol (pdf)
Rx Ativan (pdf)
Rx Antifungal (pdf)
Rx Anusol Sup ... (pdf)
Rx Augmentin (pdf)
Rx Bactrim DS (pdf)

Bentyl (pdf)

Rx Calmoseptine pdf

Rx Capsaicin (pdf)
Rx Cipro (pdf)
Rx Cotton Roll (pdf)

Rx Diflucan (pdf)
Rx Dilaudid (pdf)

Rx Diltiazem (pdf)
Rx Dexilant

Rx Exparel (pdf)
Rx Flagyl (pdf)
Rx H Pylori

Rx Imiquimod (pdf)

Rx Inderal (pdf)

Rx Intron A (pdf)
Rx Lidocaine Oint (pdf)

Rx Lidocaine Crm (pdf)

Rx Nifedipine/Lido (pdf)

Rx Nitroglycerin Oint (pdf)

Rx Novacort (pdf)
Rx NuLYTELY (pdf)

Rx Orabase Paste (pdf)
Rx OsmoPrep
Rx OTC Major Surgery

Rx Percocet (pdf)
Rx Phenergan

Rx Pilonidal Package (pdf)

Rx Podofilox (pdf)
Rx Prilosec

Rx ProCort (pdf)
Rx Proctofoam HC (pdf)
Rx Pyridium (pdf)
Rx RectaGel HC

Rx RECTIV

Rx TCA Elavil (pdf)

Rx SNRI Cymbalta (pdf)

Rx Suprep (pdf)
Rx TriLyte (pdf)
Rx Tylenol #3 (pdf)

Rx Ultram (pdf)
Rx Valium (pdf)

Rx Veregen (pdf)

Rx Viagra (pdf)
Rx Vicodin (pdf)
Rx Vytone

Rx Z Pack (pdf)
Rx Zantac (pdf)

Rx Zepbound (pdf)

Rx Zofran (pdf)