The Professional Will: Sample

 

Your letterhead

---

 

THERAPIST’S NAME: __________________________________

ADDRESS: __________________________________

This document is intended to direct the executor of my professional will in conducting the disposition of my practice in the event of my death or disability. All clinical and billing records should be made available to my professional executor and team who are aware of their clinical, ethical and legal responsibilities and duties in regard to clinical records. If the executor can not be reached or is not able to participate, the first listed team member will assume the role.

Executor:

Name:
Profession & License:
Phone:
Fax:
Email:
Address:

Team Member:

Name:
Profession & License:
Phone:
Fax:
Email:
Address:

Team Member:

Name:
Profession & License:
Phone:
Fax:
Email:
Address:

As agreed, the executor and team members will be reimbursed as follows:

Additional contact information:
Executor of personal will:
Medicating psychiatrist:
Power of attorney:
Attorney:
Clinical referrals:
Secretary:
Billing agent:
Accountant:
Answering service manager:
Building manager:
Others:

OFFICE RECORDS AND SECURITY
Office Location:

Keys/codes:

Other practice locations:

Current schedule:

Digital files codes:

Billing records:

Clinical records:

Former Clients
Current Clients

Answering machine/service information and access code:

Others:

I would like my clients notified in the following way:

This is how I would like ending charges to be managed:

Please notify the following professionals and organizations:

Professional liability insurance carrier (Policy #xxx):
Licensing board (License #xx):
Professional associations:
Medicating psychiatrist/s:
Colleagues:
Others:

My estate will pay expenses related to the disposition of my practice. These expenses will include but are not limited to:

Tasks I know will be related to the disposition are:

Copies of this document were given to:
Executor of the professional will:
Team member
Team member
Team member
Attorney

Name: ______________________

Signature: ___________________

Date: _______________

 
Top of Page