PF-ALL-0079-12 Pediatric Encounter formWACMAP-2026

1. Click ‘Get Form’ to open the PF-ALL-0079-12 Pediatric Encounter formWACMAP in the editor.
2. Begin by filling out the Member Information section. Enter the Last Name, First Name, and Member ID # accurately.
3. Next, provide the Provider Information. Fill in the Provider Name, Phone #, Provider ID, Date of Birth, Fax, Date of Visit, and Address.
4. In the Preventive/Physical section, indicate the Age and check at least one CPT (Procedure) Code that applies to the visit.
5. 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.
6. Complete any additional sections such as Immunizations and Laboratory Tests/Screening as necessary for comprehensive documentation.
7. Finally, ensure to print your name and sign where indicated before submitting the form.

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