What Is a Medical Encounter Form?

These forms may look different depending on the medical professional a person visits. However, they are required to have 13 different fields on them, including patient name, patient medical record number, date of birth, date of service, place of service, CPT-4 procedural code and description of service, modifier information, resident involvement, diagnosis code, billing instruction, space for documenting the special billing instruction, provider name and provider signature, and date.