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Progress Note

This document is a progress note form for a mental health provider. It includes fields for the date, procedure code, time spent on the encounter, activity type, and number of clients represented. It also has signature lines for the provider and co-signer. The purpose is to document a patient encounter and bill for services rendered.

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jeffrey_king
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© Attribution Non-Commercial (BY-NC)
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Download as PDF, TXT or read online on Scribd
127 views

Progress Note

This document is a progress note form for a mental health provider. It includes fields for the date, procedure code, time spent on the encounter, activity type, and number of clients represented. It also has signature lines for the provider and co-signer. The purpose is to document a patient encounter and bill for services rendered.

Uploaded by

jeffrey_king
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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MH 515

Revised 02/06/08 PROGRESS NOTE

Date: ____________ Telephone Contact: Y N Rendering Provider Face-to-Face/Other Time* (Hrs:Mins): _____________
Procedure Code: _______________ Other Staff Initials: ________ Total Time* (Hrs/Mins): _____________
* All travel and documentation time must be recorded as “Other” or “Total Time” Other Staff Initials: ________ Total Time* (Hrs/Mins): _____________
MHS Activity Type: Assessment Ind Tx Ind Reh Col PsyT Team Conf/CaseCon Other Activity Type: Cris lnt
GrpTx GrpReh # of Clients Represented: ___________ TCM

Continued (Sign & complete claim information on last page of note.)

_______________________________________________ _____________ ______________________________________________ ____________


Signature & Discipline Date Co-signature & Discipline Date
This confidential information is provided to you in accord with
State and Federal laws and regulations including but not limited to Name: IS#:
applicable Welfare and Institutions Code, Civil Code and HIPAA
Privacy Standards. Duplication of this information for further Agency: Provider #:
disclosure is prohibited without the prior written authorization of
the patient/authorized representative to who it pertains unless
otherwise permitted by law. Los Angeles County – Department of Mental Health

PROGRESS NOTE

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