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PF-ALL-0079-12 Pediatric Encounter formWACMAP-2026
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- Click ‘Get Form’ to open the PF-ALL-0079-12 Pediatric Encounter formWACMAP in the editor.
- Begin by filling out the Member Information section. Enter the Last Name, First Name, and Member ID # accurately.
- Next, provide the Provider Information. Fill in the Provider Name, Phone #, Provider ID, Date of Birth, Fax, Date of Visit, and Address.
- In the Preventive/Physical section, indicate the Age and check at least one CPT (Procedure) Code that applies to the visit.
- For Diagnosis Codes, specify primary, secondary, and tertiary codes as required. If wellness care elements were performed, mark a well code as a secondary diagnosis.
- Complete any additional sections such as Immunizations and Laboratory Tests/Screening as necessary for comprehensive documentation.
- Finally, ensure to print your name and sign where indicated before submitting the form.
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