Patient Encounter Form

Patient Encounter Form
Date
MonthDayYear
Date
Patient Information
Name
First NameLast Name
Patient ID Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Date of birth
MonthDayYear
Date
Age
Payment Method
Primary ID Number
Primary Group Number
Secondary ID Number
Secondary Group Number
Payment Method
CashCredit CardOther
Visit Information
Rendering Physician
First NameLast Name
Referring Physician
First NameLast Name
Reason for Visit
Modifiers
E/M Modifers
Unrelated E/M service during postop.Significant, separately identifiable E/MDecision for surgery
Procedure Modifers
Unusual, excessive procedureSignificant, separately identifiable E/MBilateral procedureDecision for surgeryMultiple surgical procedures on the same dayReduced/incomplete procedurePostop. management onlyDistinct multiple proceduresOther
Category
Office Visit- New Patient
MOD FEE Comments
Minimal office visit - 99201
20 minutes - 99202
30 minutes - 99203
45 minutes - 99204
60 minutes - 99205
Other
Office Visit — Established
MOD FEE Comments
Minimal office visit - 99211
10 minutes - 99212
15 minutes - 99213
25 minutes - 99214
40 minutes - 99215
Other

General Procedures

Supplies

Patient Information