Encounter Forms

The link below for the Pediatric Encounter Form is in Excel format

Please feel free to:

• Use this tool to assist you in coding for claims submission and pay for performance measure
• Modify the form to best suit your practice needs
• Add medications, procedures, and other services that you frequently offer

The ICD-10 codes have been provided for your use, beginning 10/01/2015

• Pediatric Encounter Form
• IM Encounter Form