Medical Office Policies and Procedures: Manual Template and Examples

A medical office policies and procedures manual only works if staff can find the current version and know they're expected to follow it. Below you'll find a copyable template and the sections most practices include. There are example policies for employees and for patients, a plain explanation of what HIPAA says about keeping policies and email (with citations for your editor or counsel to confirm), and a review checklist. Treat everything here as a starting point to adapt with your legal counsel and privacy officer. It is not legal advice.

What a medical office policies and procedures manual is (and the template)

A policy states the rule: "Copays are collected at check-in." A procedure states the steps, who does them and when: "The front desk verifies the copay amount in the practice management system, collects payment before rooming, and records it on the day sheet." A manual collects both, organized by area, with one owner and a review date on every policy.

Use the same structure for every policy so staff always know where to look.

POLICY TITLE:
Policy number:                Version:
Manual section: Administration / Employee / Front desk / Privacy and security / Financial / Safety and facilities

Purpose:          Why this policy exists (1–2 sentences).
Scope:            Who it applies to (roles, locations) and what it covers.
Policy statement: The rule, in plain language.
Procedure:        Numbered steps: what happens, who does it, by when.
Owner:            Role accountable for this policy (e.g., Practice Administrator).
Approved by:                  Approval date:
Effective date:               Next review date:
Related procedures and forms:
Regulatory references:        Citation, if any, confirmed by counsel
Version history:  Date | Change | Approved by
Staff sign-off:   How acknowledgement is collected and where it is stored.

Have your counsel and privacy officer review the template before you fill it in, especially the regulatory references and the privacy and security section. For more checklists and templates for practice teams, browse the operations library for clinics and practices and the free HIPAA tools and templates.

Sections to include in the manual

Most outpatient practices organize the manual into six areas. Assign each section an owner, even if one person owns several.

Section	What it covers	Typical owner
Administration	Org chart, roles, chain of approval, how policies are created, reviewed and retired	Practice administrator
Employee policies	Attendance and time off, dress code, conduct, confidentiality, device and personal messaging use, onboarding and training	HR or practice administrator
Front desk and patient flow	Check-in, scheduling, cancellations and no-shows, phone etiquette, what staff may and may not discuss with patients	Front desk lead or clinic manager
Privacy and security	HIPAA privacy and security policies, minimum necessary, access and offboarding, incident reporting	Privacy officer and security officer
Financial	Payment collection, refunds, write-offs, cash handling, billing escalation	Billing manager or practice administrator
Safety and facilities	Emergency procedures, supply ordering, equipment maintenance	Clinic manager

Write down in the administration section who can approve a new policy, who can change one, and how a retired policy is archived. In most practices this sits with the practice manager. For how that role divides responsibilities, see practice manager role and duties.

Example policies for employees

Each example uses the same format: policy statement, scope, procedure steps, owner, review date. Adapt the wording to your practice.

Example 1: Internal communication policy

• Policy statement: Work messages between staff go only through practice-approved tools. Protected health information (PHI) is never sent through personal messengers, SMS group texts or personal email.
• Scope: All employees, contractors and temporary staff at all locations.
• Procedure:
  1. Staff use the approved team chat workspace for operational messages, such as schedule changes, supply requests and front desk coverage. If the workspace will contain PHI, it must be on a plan covered by a signed BAA.
  2. Practice-wide announcements are posted in the announcements channel and pinned there.
  3. Urgent clinical matters follow the practice's clinical escalation protocol, not staff chat.
  4. Existing personal group chats used for work are closed within 30 days of this policy taking effect.
• Owner: Practice administrator, with the privacy officer.
• Review date: Annually, or when a new communication tool is approved.

Example 2: Confidentiality and acceptable discussion with patients

Where should a medical assistant look for policies that explain what they can discuss with patients? In the manual's front desk section and its privacy and security section. Those sections should be kept in one location that every new hire is shown on day one.

• Policy statement: Staff discuss patient information only with the patient or an authorized representative, only to the extent needed for the task, and never in public areas.
• Scope: Front desk, medical assistants, billing and any staff with patient contact.
• Procedure:
  1. Verify identity using two identifiers before discussing an account or appointment.
  2. Refer clinical questions (results, diagnoses, medication changes) to the clinician. Front desk staff do not interpret results.
  3. Do not confirm whether a person is a patient to callers who are not authorized.
  4. Report a suspected disclosure to the privacy officer the same day.
• Owner: Privacy officer.
• Review date: Annually.

Example 3: Onboarding and policy acknowledgement

• Policy statement: Every new employee reviews the manual sections relevant to their role and signs an acknowledgement before working unsupervised.
• Scope: All new hires and rehires.
• Procedure:
  1. On the hire date, the manager is assigned an onboarding task with a deadline of the fifth working day.
  2. The new hire reviews the employee, privacy and role-specific sections with their manager.
  3. The new hire signs the acknowledgement form. The signed copy goes into the personnel file.
  4. The manager closes the task once the signed form is filed.
• Owner: HR or practice administrator.
• Review date: Annually.

Pair this with the medical front desk training checklist for role-specific training. For the wider staffing context, see HR in healthcare.

Example policies for patients

Some policies are written for patients and published by the office. Keep the patient-facing wording separate from the internal procedure that tells staff how to apply it.

Patient-facing policy	What patients see	Internal procedure that applies it
Financial and payment policy	When payment is due, accepted payment methods, what happens with unpaid balances	Who collects, how payments are recorded, how payment plans are approved
Cancellation and no-show policy	Notice required, any fee, how to reschedule	Who logs no-shows, when a fee is applied, who can waive it
Notice of Privacy Practices	How the practice uses and discloses health information and the patient's rights	How the notice is provided, how acknowledgement is collected, who answers questions

Patient-facing policies reach patients through the practice's existing patient channels, such as intake paperwork, the website, the patient portal or a posted notice. Internal staff chat is for staff. It is where the team discusses how to apply a policy, not how it is delivered to patients.

How medical office procedures support financial policies

A financial policy sets the rule. Procedures make it repeatable: who does it, how it is recorded and what happens when something doesn't match. Without a procedure, "collect copays at check-in" depends on whoever is at the desk that day.

Here is an outline of how procedures support financial policies:

• They assign responsibility. Each step has a named role. For example, the front desk collects and the billing manager reconciles.
• They standardize recording. Every payment, refund and adjustment is logged the same way, so the end-of-day totals can be checked.
• They define exceptions and escalation. The procedure says who approves a refund, a write-off or a waived no-show fee, and above what amount.
• They separate duties. The person who takes cash does not reconcile the drawer or post adjustments.
• They create a review point. Daily reconciliation and monthly write-off review catch errors before they compound.
• They set deadlines for follow-up. Each open item, such as a denied claim or an unverified insurance policy, has an owner and a due date.

Typical examples:

• Daily cash reconciliation: The front desk counts the drawer at close. A second person compares the count to the day sheet, and the clinic manager reviews any difference over the set threshold.
• Refund approval: Billing confirms the overpayment, and the practice administrator approves refunds above a set amount.
• Insurance verification: Front desk verifies eligibility a set number of days before each visit and flags failures to billing.

Most financial errors in a practice come from follow-up nobody owned, not from the policy itself. When each open item is assigned to a person with a deadline, it stays visible until someone closes it.

HIPAA email retention: what the rule requires

What HIPAA requires you to retain. The HIPAA Security Rule requires covered entities to retain required policies, procedures and documentation for six years from the date of creation or the date when last in effect, whichever is later (45 CFR 164.316(b)(2)). The Privacy Rule has a parallel documentation requirement (45 CFR 164.530(j)). In practice, this means archiving superseded versions of your manual, not deleting them.

What HIPAA does not say about email. HIPAA does not set a single retention period for email as such. How long you keep an email depends on what it contains:

If the email is…	Retention is governed by…
Documentation HIPAA requires (e.g., a policy, a complaint and its disposition)	HIPAA documentation rules: six years (45 CFR 164.316(b)(2) and 164.530(j))
Part of the patient's medical record	State medical record retention law
Billing, payroll or HR correspondence	Other federal and state rules that apply to those records
Routine operational messages with no record value	Your own retention policy

Medical record retention and HIPAA documentation retention are separate obligations. Medical record periods are set mainly by state law, so a multi-state practice may need different periods for different locations.

Sample HIPAA email retention policy outline

1. Scope: Which mailboxes and message types are covered.
2. Retention period: By category, using the table above.
3. Storage: Where retained email is kept and in which system.
4. Access controls: Who can search or export retained email.
5. Deletion procedure: How expired email is deleted, by whom and how it is logged.
6. Legal hold: Who can suspend deletion when litigation or an investigation is expected.
7. Owner: Usually the privacy or security officer.
8. Review date: Annually.

Apply the same thinking to staff chat. Decide what is retained, for how long and who can access it, and write that into the internal communication policy. For how Chanty handles encryption, hosting and the BAA, see security, HIPAA and BAA details.

Keeping the manual current and where staff actually use it

A manual goes stale when nobody owns it and changes happen silently. A few habits prevent that:

• One owner per policy. Each policy also carries a review date and a version history.
• Announce changes instead of editing quietly. Every change gets a short announcement that says what changed, why, and when it takes effect.
• One current location. Keep the controlled master copy and archived versions wherever your practice keeps official records. Share only the current version where staff actually work.

In Chanty, files and procedures can be shared in the workspace and pinned in team channels. That way the front desk at every location opens the same current version. Announcements reach staff across shifts and locations. On Business and Enterprise, company-wide announcements and scheduled posts are available.

When a policy changes, turn it into an assigned task with an owner and a deadline. For example: "Retrain front desk on the new cancellation procedure. Owner: front desk lead. Due: Friday." Chanty does not record policy attestations or read confirmations, so keep signed acknowledgements in your HR or personnel files.

Compliance depends on the plan:

• Business and Enterprise: These plans include customizable roles, retention settings and a signed BAA, which together support HIPAA compliance. The BAA covers all data in the team space, including messages, files, voice notes, tasks and Teambook, and admins can set retention workspace-wide or per conversation.
• Free plan: There is no BAA, and PHI should not be stored.
• Integrations: Third-party integrations such as Google Drive or Dropbox are outside Chanty's BAA scope.

Chanty is internal staff communication used alongside your EHR and patient systems. It supports your compliance program but does not make the office compliant on its own. More on HIPAA-compliant chat for staff, or start a Chanty workspace.

Policy review checklist

Run this for each policy at least once a year:

• Owner assigned and still in the role
• Effective date and next review date recorded
• Legal and privacy review completed where required
• Staff notified of changes with an announcement
• Training completed for affected roles
• Old version archived and retained for six years

Run an off-cycle review when any of these happen:

• A regulation or payer rule changes
• A new location opens
• A new system goes live, such as a new practice management system or a new communication tool
• An incident or near miss points to a gap

Bring policy changes into the daily huddle template so the team hears about them the same day. Staff on later shifts can pick them up through the end-of-shift report and operational handoff. Use the front desk training checklist to retrain affected staff.

FAQ

What should a medical office policies and procedures manual include?

Six areas: administration, employee policies, front desk and patient flow, privacy and security, financial, and safety and facilities. Each policy should list its purpose, scope, owner, effective date, review date, version and related procedures.

What is the difference between a policy and a procedure in a medical office?

A policy is the rule, such as "copays are collected at check-in." A procedure is the set of steps that carries out the rule, with who does each step and when.

Where should staff look for office policies about what they can discuss with patients?

In the manual's front desk section and its privacy and security section. The manual should be kept in one known location that every new hire is shown during onboarding.

How long does HIPAA require you to keep emails?

HIPAA does not set one retention period for all email. Emails that are required HIPAA documentation follow the six-year documentation rule. Emails that are part of a medical record follow state law. Other emails follow your own retention policy.

How long must HIPAA policies and procedures be retained?

Six years from the date of creation or the date when last in effect, whichever is later (45 CFR 164.316(b)(2) and 164.530(j)).

How often should a medical office review its policies?

At least annually. Also review off-cycle after a regulation change, a new location, a new system or an incident.

Can staff use WhatsApp or text groups to share office policies or discuss patients?

Most practices prohibit PHI in personal messengers and SMS groups. Personal accounts leave access and retention outside the practice's control, and any service that handles PHI needs a signed BAA with the practice first. Set an approved tool in your internal communication policy and close informal work groups.

Does storing the policy manual in a team chat tool make a practice HIPAA compliant?

No. A tool with a signed BAA, such as Chanty on the Business or Enterprise plan, supports compliance. The practice is still responsible for configuring roles and permissions, managing access and offboarding, securing devices, signing the BAA before handling PHI, and training staff.