Physician: _________________________________

Patient Name: _________________________________

Calendar Mo/Y: _________________________________

Services Provided

The letter that corresponds with each service provided should be placed in column 2.

A. Regular physician development or revision of care plans

B. Review of subsequent reports of patient status

C. Review of related laboratory or other studies

D. Communication (including telephone calls not separately reported with codes 99441–99443) with other health care professionals involved in the patient's care

E. Integration of new information into the medical treatment plan or adjustment of medical therapy

F. Other (Attach additional explanatory materials on the services provided.)

Explanation for additional services provided

Date:_______/_________________________________

Date:_______/_________________________________

Date:_______/_________________________________

Monthly Total: ________________ CPT Code: _______________

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