Ill. Admin. Code tit. 77, § 635.APPENDIX A – Illinois Family Planning Clinic Visit Record | Midpage

Ill. Admin. Code tit. 77, § 635.APPENDIX A

Illinois Family Planning Clinic Visit Record

AUTHORITY: Implementing and authorized by Section 55 of the Civil Administrative Code of Illinois [20 ILCS 2310/55].DEPARTMENT OF PUBLIC HEALTH

ILLINOIS FAMILY PLANNING CLINIC VISIT RECORD

Name

Pt #

Address

Phone #

1. FORM NUMBER

C121002

12. SERVICE PROVIDERS/BCRR ENCOUNTERS

SECTION A

ALL VISITS

Medical (check one)

Counseling (check one)

1. Physician

2. SERVICE SITE NUMBER

2. Mid-Level Pract.

3. Nurse

3. PATIENT NUMBER

4. Ed./Counselor

5. Nutritionist

6. Social Worker

4. DATE OF VISIT

MO

DAY

YR

13. METHOD AT END OF THIS VISIT (check one)

1. Oral

7. Natural Method

5. PURPOSE OF VISIT (check one)

2. IUD

8. Cervical Cap

3. Diaphragm

9. Sterilization

1. Initial Visit

5. Supply Visit

4. Foam & Condom

10, Sponge

2. Annual Revisit

6. Education/Counseling Visit

5. Spermicide

11. Other

3. Routine Visit

7. Non F.P. Visit

6. Condom

12. None

4. Problem Visit

6. DATE OF BIRTH

MO

DAY

YR

14. IF NO METHOD, REASON FOR NONE (check one)

1. Pregnant

4. Other Medical Reasons

7. PRIMARY SOURCE OF PAYMENT (Check One)

2. Infertility

5. Relying on Partner's Method

3. Seeking Pregnancy

6. Other

1. Medicaid Only

4. Full Fee

15. REFERRALS MADE (check up to two codes)

2. No Fee (0-100%)

5. FWF Only

1. Sterilization

7. STD

3. Part Fee (101%-250%)

6. Medicaid and FWF

2. Gynecology

8. Other Medical

8. BILLABLE MEDICAL SERVICES

3. Prenatal

9. Other F.P. Clinic

1. Minimal Service

13. Misc. Culture

4. Other Pregnancy

10. Infertility

2. Brief/Int. Exam

14. Sickle Cell

5. Social Service

11. Nutrition

3. Extended Exam

15. PP Blood Gluc.

6. Contraception

12. Other

4. IUD Insertion

16. Cholesterol Level

SECTION B

INITIAL, ANNUALS

5. Diaphragm Fit

17. SMA-12

ZIP CODE

FIPS

6. HGB/HCT

18. Colposcopy

16. RESIDENCE CODES

7. U/A

19. Colposcopy & Biopsy

17. ETHNIC ORGIN/RACE (check one)

8. Pregnancy Test

20. Sonography/Lost IUD

1. White

4. Asian or Pacific Islander

9. VDRL

21. X-Rays/Lost IUD

2. Black

5. Hispanic

10. PAP Smear

22. Chlamydia Test

3. Native American

11. Gonococcal

23. Cervical Cap Fit

18. SEX (check one)

12. Wet Mount

24. None

1. Female

2. Male

9. BILLABLE COUNSELING SERVICES

19. EMPLOYMENT STATUS (check one)

1. Indepth/l Hr.

2. Counseling/15 min. to 1 Hr.

1. Employed

3. Not In The Work Force

10. ROUTINE COUNSELING SERVICES

2. Unemployed

1. Sterilization

4. Pregnancy

20. GROSS WEEKLY INCOME

2. Contraception

5. STD

21. FAMILY SIZE

3. Infertility

6. Natural Family Planning

22. SOURCE OF REFERRAL (check one)

11. BILLABLE CONTRACEPTIVE SUPPLIES

1. Other F.P. Clinic

6. Other Patient

Qty

Brand

Qty

Brand

2. Hospital/Health Agency

7. Family/Friend

1. Orals

8. Basal T&C

3. Private Doctor

8. Media

2. Creams

9. Contraceptive Sponges

4. Social/Church Agency

9. Hotline

3. Jellies

10. Condoms

5. School

10. Phonebook

4. Suppositories

11. Meds/Vag Inf

LOCAL USE SECTION

5. Foams

12. Meds/STD

6. Diaphragms

13. VC-Foam

A

B

C

D

7. IUD

14. Cervical Cap