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