|
Plan
• • •
|
Plan Free Type
|
|
Plan Free Type
|
Plan Free Type
|
|
|
|
|
Vaccine Counseling
|
|
|
Supportive Care
• • •
|
Supportive Care Free Type
|
|
Return if symptoms do not improve
|
|
|
New level 2 15-29 min, 3 30-44 min, 4 45-59 min, 5 60-74 min
|
|
|
Est. level 2 10-19 min, 3 20-29 min, 4 30-39 min, 5 40-45 min
|
|
|
Total minutes before, during, and after the visit
|
|
|
Time Attestation Minutes:
|
|
|
|
|
|
General Comments
|
|
|
|
|
|
Signed M.D.
• • •
|
|
|
|
|
|
S. Ballingham Signed and Complete
|
|
|
Plan
• • •
|
Plan Free Type
|
|
Plan Free Type
|
Plan Free Type
|
|
Vaccine Counseling
|
Supportive Care
• • •
|
|
Supportive Care Free Type
|
Return if symptoms do not improve
|
|
New level 2 15-29 min, 3 30-44 min, 4 45-59 min, 5 60-74 min
|
|
|
Est. level 2 10-19 min, 3 20-29 min, 4 30-39 min, 5 40-45 min
|
|
|
Total minutes before, during, and after the visit
|
Time Attestation Minutes:
|
|
General Comments
|
Signed M.D.
• • •
|
|
S. Ballingham Signed and Complete
|
|
