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Encounter Form Samples

Updated: 01/08/2021
Views: 37468

The below templates for Encounter Forms, also known as paper superbills or fee tickets, are available for use within the Kareo Desktop Application (PM). Click on a thumbnail image or title to view a sample of how the encounter form will print. Once you decide on the ones you want to use, add them within Kareo.

Thumbnail Description
Sample of One Page Encounter Form

One Page

  • A one-page form with solid grid lines.
  • Procedures on top in three columns.
  • Diagnoses are below in three columns and the last column has space for a physician's signature.
Sample of One Page Large Font Encounter Form

One Page (Large Font)

  • A one-page form with solid grid lines just like "One Page", but the fonts used for the procedures and diagnoses are larger, touching the grid lines.
  • Procedures on top in three columns.
  • Diagnoses are below in three columns and the last column has space for a physician's signature.
Sample of Two Page  Encounter Form, Page 1     Sample of Two Page Encounter Form, Page 2

Two Page — Page 1 Page 2

  • A two-page form with solid grid lines.
  • The first page contains procedures in three columns.
  • The second page contains diagnoses in three columns, and a footer with space for a physician's signature.
Sample of Two Page Encounter Form, First Page Only

Two Page (First Page Only)

  • This is the first page of the “Two Page” form with solid grid lines.
  • The page contains procedures in three columns.
  • The second page containing diagnoses and footer does not print.
Sample of Two Page Version 2 Encounter Form, Page 1     Sample of Two Page Version 2 Encounter Form, Page 2

Two Page Version 2 — Page 1 Page 2

  • A two-page form with dotted grid lines.
  • The first page contains procedures in three columns.
  • The second page contains diagnoses in three columns, and a footer with space for a physician's signature.
Sample of Two Page Version 2 Encounter Form, First Page Only

Two Page Version 2 (First Page Only)

  • This is the first page of the “Two Page Version 2” form with dotted grid lines.
  • The page contains procedures in four columns.
  • The second page containing diagnoses and footer does not print.
Sample of One Page No Grid Extended Encounter Form

One Page No Grid Extended

  • This one-page form that is blank with a header.
  • The header contains patient, insurance, appointment, account balance, and payment information.
Sample of One Page Version 2 Encounter Form

One Page Version 2

  • A one-page form with dotted grid lines.
  • Procedures are on top in four columns.
  • Diagnoses are below in four columns and takes up half the space as the procedures.
  • The footer contains a return schedule box.
Sample of Two Page Four Column Grid Encounter Form, Page 1    Sample of Two Page Four Column Grid Encounter Form, Page 2     

Two Page Four Column Grid — Page 1 Page 2

  • A two-page form with dotted grid lines.
  • The first page contains procedures in four columns, and a footer with a return schedule box.
  • The second page contains diagnoses in four columns, and a footer with space for a physician's signature.
Sample of Two Page with Recent Diagnoses Encounter Form, Page 1     Sample of Two Page with Recent Diagnoses Encounter Form, Page 2

Two Page with Recent Diagnoses — Page 1 Page 2

  • A two-page form with dotted grid lines.
  • The first page contains six recent diagnoses for the current patient and case in three columns, followed by procedures arranged in three columns.
  • The second page contains diagnoses in three columns, and a footer with space for a physician's signature.
Sample of 1 Page 3 Column with Recent Diagnoses Encounter Form

1-Page, 3-Column with Recent Diagnoses

  • A one-page form with dotted grid lines.
  • Six recent diagnoses for the current patient and case in three columns at the top, followed by the normal diagnosis list in three columns.
  • Procedures are below in three columns, and the last column of has space for a physician's signature.
Sample of 1 Page 4 Column with Recent Diagnoses Encounter Form

1-Page, 4-Column with Recent Diagnoses

  • A one-page form with dotted grid lines.
  • Eight recent diagnoses for the current patient and case in four columns at the top, followed by the normal diagnosis list in four columns.
  • Procedures are below in four columns and the last column of has space for a physician's signature.
Sample of One Page Four Column Encounter Form

One Page Four Column

  • A one-page form with solid grid lines.
  • The header contains space for patient account status and a return schedule box.
  • Procedures are on top in four columns.
  • Diagnoses are below in four columns and takes up half the space as the procedures.
Sample of One Page More Diagnoses Encounter Form

One Page More Diagnoses

  • A one-page form with dotted grid lines.
  • Procedures on top in four columns.
  • Diagnoses are below in four columns and takes up twice the space as the procedures.
  • The footer contains a return schedule box.
Sample of One Page Blank Fourth Columns Encounter Form

One Page Blank Fourth Columns

  • A one-page form with dotted grid lines.
  • Procedures on top in four columns and takes up twice as much space as diagnoses below in four columns. 
  • The last column of procedures and diagnoses is blank with no grid lines to allow for notes.
  • The last column of diagnoses has space for a physician's signature.
  • The footer contains a return schedule box.
Sample of Blank Encounter Form with Header

Blank Encounter Form with Header

  • A one-page form that is blank with a header.
  • The header contains patient, insurance, appointment, account activity, and payment information.
  • This form provides flexibility to construct the layout as desired outside of Kareo. 
Sample of 1 Page, 2 Column Procedures Encounter Form

1-Page, 2-Column Procedures

  • A one-page form with dotted grid lines.
  • Procedures on top in two columns.
  • Diagnoses are below in four columns and takes up half the space as the procedures.
  • The footer contains a return schedule box.
Sample of One Page Equal Spacing Encounter Form

One Page Equal Spacing

  • A one-page form with solid grid lines.
  • Procedures are on top in four columns.
  • Diagnoses are below in four columns and takes up an equal space as the procedures.
  • The header contains space for patient account status and a return schedule box.
Sample of One Page AO Encounter Form

One Page AO

  • A one-page form with solid grid lines and yellow highlighting for headers and footer.
  • Diagnoses on top are in four columns. 
  • Procedures are below in four columns and takes up half the space as the diagnoses.
  • The footer contains space for patient's and physician's signatures.
Sample of One Page Three Column Encounter Form

One Page Three Column

  • A one-page form with solid grid lines.
  • There are nine rows of procedures in three columns on top.
  • Diagnoses are below in three columns and takes up the rest of the page.
Sample of One Page No Grid Lines Encounter Form

One Page No Grid Lines

  • A one-page form with no grid lines.
  • Procedures are on top in four columns.
  • Diagnoses are below in four columns and takes up an equal space as the procedures.
Sample of Blank Encounter Form with Header Footer

Blank Encounter Form with Header Footer

  • A one-page form with a header and footer that is blank in the middle.
  • The header contains patient, insurance, and appointment information.
  • The footer contains account balance, account activity, and payment information. 
  • This form gives flexibility to construct the layout as desired outside of Kareo
Sample of 1 Page, No Grid Lines with More Diagnoses Encounter Form

1-Page, No Grid Lines with More Diagnoses 

  • A one-page form with no grid lines.
  • There are ten rows of procedures in four columns on top.
  • Diagnoses are below in four columns and takes up twice the space as the procedures.
Sample of  One Page DMN Encounter Form

One Page DMN

  • A one-page form with no grid lines.
  • Procedures are on top in three columns and contain space for a fee.
  • Diagnoses are below in four columns and are numbered.
Sample of One Page No Grid Lines Version 2 Encounter Form

One Page No Grid Lines Version 2

  • A one-page form with no grid lines.
  • Procedures are on top in four columns.
  • Diagnoses are below in four columns and takes up twice the space as the procedures. 
  • The form uses smaller fonts than the "One Page No Grid Lines" form, and can fit more entries in the lists.
Sample of One Page DB Encounter Form

One Page DB

  • A one-page form with no grid lines.
  • Procedures are on top in one wide column that contains spaces for modifiers and fees.
  • Diagnoses are below in two columns.
Sample of One Page No Diagnoses Section Encounter Form

One Page No Diagnoses Section

  • A one-page form with solid grid lines.
  • Only lists procedures in three columns and contains space for a fee.
  • The footer has space for a fill-in diagnosis.
Sample of 1 Page, 4 Column with 3 Insurances  Encounter Form

1-Page, 4-Column with 3 Insurances

  • A one-page form with solid grid lines.
  • The header contains a return schedule box, and has space for primary, secondary and tertiary insurance.
  • Procedures take up the vast majority of the page, arranged in four column.
  • Diagnoses are at the bottom of the page in four columns.
Sample of 1 Page, Original with More Diagnoses Encounter Form

1-Page, Original with More Diagnoses

  • A one-page form with solid grid lines.
  • Procedures on top in three columns.
  • Diagnoses are below in three columns and the last column has space for a physician's signature.
  • This form has slightly more diagnoses than "One Page" form.
Sample of 1 Page, 3 Column with Equal Spacing Encounter Form

1-Page, 3-Column with Equal Spacing

  • A one-page form with solid grid lines.
  • Procedures on top in three columns.
  • Diagnoses are below in three columns and takes up an equal space as the procedures.
Sample of 1 Page, 3 Column with 3 Insurances Big Font Encounter Form

1-Page, 3-Column with 3 Insurances Big Font

  • A one-page form with solid grid lines.
  • The page header contains a return schedule box, and has space for primary, secondary and tertiary insurance.
  • Procedures take up the vast majority of the page, arranged in three columns.
  • Diagnoses are at the bottom of the page in three columns.
Sample of One Page Four Column Grid Encounter Form

One Page Four Column Grid

  • A one-page form with dotted grid lines.
  • Procedures take up the vast majority of the page, arranged in four columns.
  • The footer contains a space for notes, a return schedule box and space for a physician's signature.
Sample of One Page Mods and Fees Encounter Form

One Page Mods and Fees

  • A one-page form with solid grid lines.
  • Procedures take up the vast majority of the page, arranged in two columns, and contains modifiers and fees.
  • Diagnoses are below in three columns and the last column has space for a physician's signature.

 

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