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OASAS Encounter Form Model Patient Name Address City State Zip 1234 Main Street Apartment B-22 Age Date of Appt Time of Appt Rochester NY 14611 Sex Appt. Type Date of Birth Jane Doe mm/dd/yyyy Phone Primary Insurance Case Subscriber Patient Client Medicaid ID Relationship to Insured Referral to/ of Visits/Notes DX1 DX2 DX3 Provider Signature Total Charges Total Payment Payment Method Cash Check MC VISA Discover AmEx Treating Provider Name O.

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