The encounter form is to be completed for each patient seen.
- Completion of services is indicated in one of five ways:
- Circle the letter “C” (completed) next to the appropriate code;
- Identify the number of films taken for Additional Periapical films;
- Note the tooth code – number (1 – 32) and letter (A – T) – for all surgical procedures, all endodontic, procedures, all sealants, and such restorative procedures as stainless steel crowns, labial veneers, and resin crowns;
- Note the tooth code and surface code for all amalgam and composite restorations;
- Circle the quadrant scaled for periodontal scalings.
- Services in progress are indicated by circling the letter “P” to the left of the service code. Services without a “P” indicate that the service is completed in one visit. Services in progress include the fitting of bands for a space maintainer, post-operative visits for surgical procedures, and endodontic visits prior to the filling of the root canal.
- The category OTHER SERVICES is to be used for those procedures not listed on the encounter form and should be completed as listed above.
- THE DENTAL PROVIDER – DENTIST AND HYGIENIST – MUST SIGN FORM AT THE BOTTOM OF THE PAGE AND INDICATE THE PROFESSIONAL DEGREE.