Patient Details:
- Patient ID: [insert patient ID number] (Enter the unique identification number assigned to the patient; include only if explicitly stated)
- Full Name: [insert patient full name] (Write the full legal name of the patient; only include if mentioned)
- Address: [insert patient address] (Enter the complete mailing address, including street, city, state, and ZIP; include only if provided)
- City/State: [insert city and state of residence] (Enter city and state components of the address if available)
- SSN: [insert Social Security number] (Include only if specifically recorded; redact or omit if not explicitly mentioned)
- Contact Number: [insert patient phone number] (Include full phone number with area code; only include if provided)
- DOB: [insert date of birth] (Write in full date format; include only if explicitly mentioned)
- Age: [insert patient age] (Enter patient's age in years; calculate only if explicitly instructed or stated)
Payment Information:
- Primary Insurance: [insert primary insurance details] (Include name of primary insurer, ID number, and group number; format as a single line unless noted otherwise)
- Secondary Insurance: [insert secondary insurance details] (Include name of secondary insurer, ID number, and group number; only include if secondary insurance is explicitly mentioned)
- Self-Pay/Credit: [insert self-pay or credit card details] (Indicate payment method if not using insurance; enter only if stated)
- Alternative Billing: [insert any alternative billing arrangements] (Enter only if specific alternative payment methods are mentioned)
Appointment Details:
- Date of Visit: [insert visit date] (Write in full date format; only include if explicitly stated)
- Visit ID: [insert visit number] (Enter the system-generated or manually assigned number identifying this specific visit)
- Attending Physician: [insert name of rendering physician] (Include full name of the physician who delivered the service; only include if stated)
- Referring Doctor: [insert name of referring physician] (Include only if a referral was explicitly noted)
- Visit Reason: [insert chief complaint or presenting reason] (Write a brief phrase or full sentence summarising the primary reason for this medical encounter; include only if specified)
Modifiers:
- E/M Modifiers: [insert applicable E/M service modifiers] (Enter any evaluation and management coding modifiers used; only include if relevant modifiers are mentioned)
- Procedure Modifiers: [insert applicable procedure-specific modifiers] (List CPT or HCPCS modifiers for performed procedures; include only if modifiers are explicitly stated)
- Additional Modifiers: [insert any other applicable modifiers] (Include additional modifiers only if recorded)
Procedure and Coding:
(Use the following structure for each selected service category; list each entry on its own line, enumerate as many as mentioned in the patient interaction)
- CATEGORY: [insert procedure or service category] (Select from the pre-listed categories: Office Visit – New Patient, Office Visit – Established, General Procedures, Wound Care, Supplies, OB Care. Only include categories explicitly referenced)
- CODE: [insert CPT or HCPCS code] (Enter the corresponding medical billing code for each selected procedure or service; include only if stated)
- MOD: [insert modifier code] (Include only if a specific modifier is linked to that code; otherwise omit)
- FEE: [insert billed amount] (Enter the fee amount for the service or procedure, in currency format; include only if stated)
Vital Signs:
- Blood Pressure: [insert blood pressure] (Write systolic/diastolic format; include only if measured and recorded)
- Heart Rate: [insert pulse rate] (Enter value in bpm; include only if recorded)
- Temperature: [insert body temperature] (Use Celsius or Fahrenheit, depending on source; include only if documented)
- Height: [insert height] (State value in feet/inches or cm as provided; only include if measured)
- Weight: [insert weight] (Enter weight in pounds or kilograms; include only if documented)
Additional Visit Information:
- Labs Ordered: [insert list of lab tests to be ordered] Write in line or list format as per form layout; only include if lab work is indicated)
- Referral: [insert referral target] (State specialist or facility referred to; only include if referral is explicitly mentioned)
- Provider Signature: [insert provider's name and signature] (Include if the clinician’s signature is documented or required)
- Follow-Up Appointment: [insert date or time frame for next appointment] (Include date or descriptive phrase such as 'in 2 weeks'; only if scheduled or mentioned)
Billing:
- Total Charges: [insert total charges] (Sum of all listed services and procedures; include only if provided)
- Copay Collected: [insert copay amount received] (Include amount paid by patient at time of service; only if documented)
- Additional Payment: [insert description and amount of other payment] (Include only if additional or nonstandard payments are recorded)
- Balance Due: [insert remaining balance due] (Calculate or record the total amount due after copay and other payments; include only if stated)