INSERT NAME OF AGENCY
COMPLETE ADDRESS, PHONE NUMBER, FAX NUMBER
Date of Service:
Clinic Presented at:
Last Name:
First Name:
Birth Date:
Age:
Phone Number:
Address:
Medicaid:
Yes
If yes, enter number:
Health Insurance:
No
Yes
Age 12 – 17 years - Adolescent
Age 18 – 39 years
Age 40 – 64 years
Established Patient Preventive Visit (Annual):
Age 12 – 17 years - Adolescent
Age 18 – 39 years
Age 40 – 64 years
New Patient Medical Visit:
99201
99202
99203
Focused Exam
Expanded Visit
Detailed Visit
Established Patient Medical Visit:
99211
99212
99213
Minimal Visit
Focused Exam
Expanded Visit
Individual Counseling
99401
99402
State:
Counseling 15 minutes
Counseling 30 minutes
Insertion of implantable contraceptive capsules
Removal of implantable contraceptive capsules
Removal/reinsertion of implantable contraceptive capsules
Diaphragm fitting (with instructions)
Insertion of intrauterine device (IUD)
Removal of intrauterine device (IUD)
Contraceptive Supplies:
A4266
A4267
A4268
A4269
J1055
J7300
J7302
J7303
J7304
J7307
S4993
Diaphragm
Condom, male
Condom, female
Spermicide
Contraceptive injectable
Intrauterine device, Paragard
Intrauterine device, Mirena
Hormone releasing vaginal ring Nuvaring - each)
Hormone containing patch (Evra - each)
Etonogestrel Implant, 68 mg. (Implanon)
Oral contraceptives (per cycle)
Lab Codes:
81000
82270
82948
85013
85018
86701
87210
Q0111
99000
36415
36416
Urinalysis, non automated
Fecal Occult Blood Screening
Glucose, blood reagent strip
Spun Microhematocrit
Hemoglobin
Rapid HIV 1
Smear, Wet Mount
Smear, Wet Mount with prep
Lab handling
Venipuncture (blood draw)
Collection of capillary blood specimen (finger stick)
Zip:
Group Number:
Other Codes – Female Genital System:
56501
56605
+56606
57061
57420
57421
57511
+58110
Destruction of lesion/s on vulva, simple
Biopsy of vulva or perineum, one lesion
Each separate additional lesion
Destruction of vaginal lesions, simple
Colposcopy of the entire vagina, with cervix if present
Colposcopy of the entire vagina, with cervix if present,
with biopsy
Colposcopy of the cervix, including upper/adjacent vagina
Colposcopy of the cervix, including upper/adjacent vagina,
with biopsy
Cryocautery of the cervix, initial or repeat
Endometrial sampling in conjunction with colposcopy
00921
54050
54060
55250
Anesthesia for vasectomy, unilateral or bilateral
Destruction of lesions on penis, chemical
Destruction of lesion/s on penis, surgical excision
Vasectomy, unilateral or bilateral
57452
57454
Other Codes – Male Genital System:
Other Supplies:
Procedures:
11975
11976
11977
57170
58300
58301
Male
Insurance Phone Number:
Policy Number:
New Patient Preventive Visit (Initial):
Female
Alt. Phone Number:
If yes, enter Insurance Company:
Policy Holder’s Name:
99394
99395
99396
Gender:
City:
No
99384
99385
99386
Middle Initial:
<List all other therapeutics you carry here; These cannot be
billed to Medicaid>
Diagnosis Codes:
V25.0
V25.01
V25.02
V25.03
V25.04
V25.09
V25.1
V25.2
V25.4
V25.40
V25.41
V25.42
V24.43
V25.49
V25.5
V25.8
V25.9
939.2
Patient Signature: ________________________________________________
Encounter for contraceptive management:
General counseling and advice
Prescription of oral contraceptives
Initiation of other contraceptive device
Encounter for emergency contraceptive counseling and
prescription
Counseling/instruction Natural Family Planning
Other counseling and advice for contraceptive
management
Insertion of intrauterine contraceptive
Sterilization - Vasectomy
Surveillance of previously prescribed contraceptive
method/s
Contraceptive surveillance, unspecified
Contraceptive pill
Intrauterine contraceptive device
Implantable subdermal contraceptive
Other contraceptive method
Insertion of implantable subdermal contraceptive
Other specified contraceptive management
Unspecified contraceptive management
Tampon Removal
Income Level
Today’s Charges
Discounted Charge
Amount Paid
Balance Due
Donation
1 2
$
$
$
$
$
3
4 5
Form rev. 03/2009