Forms, Templates and Resources
DO YOU NEED THAT PERFECT FORM FOR YOUR PRACTICE?
The following forms are researched, flexible, accurate, and easily tailored to your practice needs. KAC members in good standing can download, edit, and continue to utilize these forms and templates for FREE in their offices throughout their membership lives (please see licensing terms and conditions below). Downloading is an easy one-step process – When you select to download a form below, we will take you to your account and automatically download the form.
Click on the form name or the + to expand the category listing. Once expanded, you will find a link to the various forms and templates along with a link to an article that explains how to use the linked form. Jump to your needed category by clicking a category button here:
Good Faith Estimates
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Good Faith Estimates
| Template | Good Faith Estimate Language for Website | Explanation |
| Form | Patient Good Faith Estimate Form | Explanation |
| Template | Right to Receive A Good Faith Estimate | Explanation |
| Information | KY Easy to read flow chart | Explanation |
| Information | CMS FAQs | Explanation |
| Information | Required poster for your office | Explanation |
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Insurance
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ICD-10 Resources
| Resource | ICD-10 Quick Reference Guide | Updated 10.01.2023 |
Lien Resources
| Template | UCC Lien | Explanation |
Medicare Advanced Beneficiary Notice
| Form – expires 6.2023 | Advance Beneficiary Notice of Noncoverage ABN – English | |
| Form – expires 6.2023 | Advance Beneficiary Notice of Noncoverage ABN – Spanish | |
| Resource – expires 6.2023 | Form Instructions Advance Beneficiary Notice of Noncoverage |
The ABN, Form CMS-R-131, and form instructions are expiring as of June 30, 2023. The NEW ABN form has been issued by CMS. The use of the renewed form with the expiration date of 01/31/2026 will be mandatory on 6/30/23.
You may continue to use the ABN form with the expiration date of 6/30/23 until the renewed form (expiration date 01/31/2026) becomes mandatory on 6/30/23. However, don’t forget! If you continue to use the expired version of the form after June 30, 2023, Medicare will deem the form to be defective and may demand that you refund the patient.
| 06.2023 ABN | All Resources for June 2026 ABN form – includes instructions, Spanish and English forms | Click here |
Anthem Resources
| AIM Postpone Indefinitely letter from DOI | Click here | |
| Indiana Alpha pre-fix list | Click here | |
| Ohio Alpha pre-fix list | Click here | |
| 2023 Provider Rep list | Click here |
Medicaid Resources
| DMS Renewal Instructions | Click here |
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Foundation for Chiropractic Progress Resources
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2022 Foundation for Chiropractic Progress Monthly Marketing Resources
2023 Foundation for Chiropractic Progress Monthly Marketing Resources
2024 Foundation for Chiropractic Progress Monthly Marketing Resources
| Download Link | |
| January 2024 Marketing Road Map Only | 01.2024 F4CP Full Marketing Materials |
| February 2024 Marketing Road Map Only | 02.2024 F4CP Full Marketing Materials |
| March 2024 Marketing Road Map Only | 03.2024 F4CP Full Marketing Materials |
| April 2024 Marketing Road Map Only | 04.2024 F4CP Full Marketing Materials |
| May 2024 Marketing Road Map | 05.2024 F4CP Full Marketing Materials |
| June 2024 Marketing Road Map | 06.2024 F4CP Full Marketing Materials |
| July 2024 Marketing Road Map Only | 07.2024 F4CP Full Marketing Materials |
| August 2024 Marketing Road Map Only | 08.2024 F4CP Full Marketing Materials |
| September 2024 Marketing Road Map Only | 09.2024 F4CP Full Marketing Materials |
| October 2024 Marketing Road Map Only | 10.2024 F4CP Full Marketing Materials |
| November 2024 Marketing Road Map Only | 11.2024 F4CP Full Marketing Materials |
| December 2024 Marketing Road Map | 12.2024 F4CP Full Marketing Materials |
F4CP Videos
| Download Link | |
| 2023 Olivia Athens Chiropractic Video | Click here |
| 2023 F4CP Commercial | Click here |
| 2023 F4CP Pregnancy Commercial | Click here |
| 2020 F4CP Olympic Commercial | Click here |
Social Media Covers
| Download Link | |
| 2022 Better Posture Social Media Cover | Click here |
| 2022 Drug Free management | Click here |
| 2022 Effective Care | Click here |
| 2022 Fall Prevention | Click here |
| 2022 Family Care | Click here |
| 2022 Health Workforce | Click here |
| 2022 Low back pain | Click here |
| 2022 Military and Vet care | Click here |
| 2022 Optimal Performance | Click here |
| 2022 Optimized Health | Click here |
| 2022 Personal Injury Care | Click here |
| 2022 Women’s health | Click here |
| 2023 Falls Prevention | Click here |
| 2023 Choose Chiropractic | Click here |
| 04.2023 Choose Chiropractic | Click here |
| 05.2023 Choose Chiropractic | Click here |
| 06.2023 Choose chiropractic | Click here |
| 07.2023 Choose Chiropractic | Click here |
| 08.2023 Choose Chiropractic | Click here |
| 09.2023 Choose Chiropractic | Click here |
| 10.2023 Choose Chiropractic | Click here |
| 11.2023 Choose Chiropractic | Click here |
| 12.2023 Choose Chiropractic | Click here |
| 2024 | |
| 01.2024 F4CP FB Cover Photos | Click here |
| 02.2024 F4CP FB Cover Photos | Click here |
| 03.2024 F4CP FB Cover Photos | Click here |
| 04.2024 F4CP FB Cover Photos | Click here |
| 05.2024 F4CP FB Cover Photos | Click here |
| 06.2024 F4CP FB Cover Photos | Click here |
| 07.2024 F4CP FB Cover Photos | Click here |
| 08.2024 F4CP FB Cover Photos | Click here |
| 09.2024 F4CP FB Cover Photos | Click here |
| 10.2024 F4CP FB Cover Photos | Click here |
| 11.2024 F4CP FB Cover Photos | Click here |
| 12.2024 F4CP FB Cover Photos | Click here |
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Miscellaneous Resources
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HR 1610 Patient - Medicare QR Code
| Download Link | |
| HR 1610 Patient QR code – PNG | Click here |
| HR 1610 Patient QR code – PDF | Click here |
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The Kentucky Association of Chiropractors, Inc. (KAC) grants exclusively to KAC members in good standing (“authorized users”) a non-transferable license to use KAC Forms, Templates and Resources above for the purposes set out in the full terms and conditions. Your use of our site and its Forms and Templates constitute your agreement to abide by the Terms of Use and License of KAC Forms, Templates and Resources.
As a reminder, this License terminates for any Kentucky Association of Chiropractors member user at such time as the member is no longer in good standing according to the KAC bylaws. Users who are not in good standing, including without limitation those who are not current in payment of dues, are not authorized to use KAC forms, templates and resources, and any such use is strictly prohibited.