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Get Amerigroup OB/GYN Encounter Form

E: Phone #: Provider ID #: Date of Birth: Fax #: Date of Visit: Address: Level of Care: Please circle at least one CPT (Procedure) Code. Office Visit Counseling Established New Patient Established Code Length of Time Patient Patient 12–17 99384 99394 99201 99211 99401 15 minutes 18–39 99385 99395 99202 99212 99402 30 minutes 40–64 99386 99396 99203 99213 99403 45 minutes 65+ 99387 99397 99204 99214 99404 60 minutes 99205 99215 Diagnosis Codes: Please indicate primary, secondary, and tert.

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