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Name
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Pt
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Address
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Phone
#
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1.
FORM NUMBER
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C121002
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12.
SERVICE PROVIDERS/BCRR ENCOUNTERS
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SECTION
A
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ALL VISITS
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Medical
(check one)
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Counseling
(check one)
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1.
Physician
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2.
SERVICE SITE NUMBER
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2.
Mid-Level Pract.
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3.
Nurse
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3.
PATIENT NUMBER
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4.
Ed./Counselor
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5.
Nutritionist
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6.
Social Worker
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4.
DATE OF VISIT
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MO
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DAY
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YR
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13.
METHOD AT END OF THIS VISIT (check one)
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1. Oral
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7. Natural Method
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5.
PURPOSE OF VISIT (check one)
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2. IUD
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8. Cervical Cap
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3. Diaphragm
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9.
Sterilization
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1. Initial Visit
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5. Supply Visit
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4. Foam & Condom
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10,
Sponge
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2. Annual Revisit
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6. Education/Counseling Visit
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5. Spermicide
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11.
Other
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3. Routine Visit
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7. Non F.P. Visit
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6. Condom
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12.
None
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4. Problem Visit
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6.
DATE OF BIRTH
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MO
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DAY
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YR
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14.
IF NO METHOD, REASON FOR NONE (check one)
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1. Pregnant
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4. Other Medical Reasons
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7. PRIMARY SOURCE OF PAYMENT (Check One)
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2. Infertility
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5. Relying on Partner's Method
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3. Seeking Pregnancy
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6. Other
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1. Medicaid Only
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4. Full Fee
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15.
REFERRALS MADE (check up to two codes)
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2.
No Fee (0-100%)
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5. FWF Only
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1. Sterilization
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7. STD
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3.
Part Fee (101%-250%)
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6. Medicaid and FWF
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2. Gynecology
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8. Other Medical
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8. BILLABLE MEDICAL SERVICES
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3. Prenatal
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9. Other F.P. Clinic
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1. Minimal Service
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13. Misc. Culture
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4. Other Pregnancy
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10. Infertility
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2. Brief/Int. Exam
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14. Sickle Cell
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5. Social Service
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11. Nutrition
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3. Extended Exam
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15. PP Blood Gluc.
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6. Contraception
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12. Other
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4.
IUD Insertion
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16. Cholesterol Level
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SECTION B
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INITIAL, ANNUALS
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5. Diaphragm Fit
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17. SMA-12
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ZIP CODE
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FIPS
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6. HGB/HCT
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18. Colposcopy
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16.
RESIDENCE CODES
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7. U/A
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19. Colposcopy & Biopsy
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17.
ETHNIC ORGIN/RACE (check one)
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8. Pregnancy Test
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20. Sonography/Lost IUD
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1. White
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4. Asian or Pacific Islander
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9. VDRL
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21. X-Rays/Lost IUD
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2. Black
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5. Hispanic
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10. PAP Smear
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22. Chlamydia Test
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3. Native American
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11. Gonococcal
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23. Cervical Cap Fit
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18.
SEX (check one)
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12. Wet Mount
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24. None
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1. Female
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2. Male
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9.
BILLABLE COUNSELING SERVICES
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19.
EMPLOYMENT STATUS (check one)
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1. Indepth/l Hr.
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2. Counseling/15 min. to 1 Hr.
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1. Employed
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3. Not In The Work Force
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10. ROUTINE COUNSELING SERVICES
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2. Unemployed
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1. Sterilization
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4. Pregnancy
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20.
GROSS WEEKLY INCOME
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2. Contraception
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5. STD
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21.
FAMILY SIZE
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3. Infertility
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6. Natural Family Planning
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22.
SOURCE OF REFERRAL (check one)
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11. BILLABLE CONTRACEPTIVE SUPPLIES
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1. Other F.P. Clinic
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6.
Other Patient
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Qty
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Brand
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Qty
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Brand
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2. Hospital/Health Agency
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7.
Family/Friend
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1. Orals
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8. Basal T&C
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3. Private Doctor
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8.
Media
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2. Creams
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9. Contraceptive Sponges
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4. Social/Church Agency
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9.
Hotline
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3. Jellies
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10. Condoms
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5. School
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10.
Phonebook
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4. Suppositories
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11. Meds/Vag Inf
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LOCAL USE SECTION
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5. Foams
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12. Meds/STD
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