Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. Enter the numbers representing the date of service in these boxes. Enter the month as a number from 01 to 12 for January through December. In the boxes provided, enter the CPT code for the type of visit.
Space is provided for up to seven types of visits.
In the boxes provided under Other Specialists , write in specialties not listed. Write in to the nearest dollar the amount charged for durable medical equipment. If the amount is less than four digits, please right justify the numbers entered into the boxes provided. If the client is participating in a clinical trial or trials, darken this bubble. You may use either version of the form.