Patient Encounter and Authorization Tracking Form Completed Form Examples and Samples
Explore detailed examples and free samples of a Patient Encounter and Authorization Tracking Form. Our filled-out templates demonstrate how to correctly document patient encounters, track insurance pre-authorizations, and manage CPT/ICD-10 codes for efficient medical billing and practice management.
Patient Encounter and Authorization Tracking Form Example
How this form was filled:
This example shows a completed Patient Encounter and Authorization Tracking Form for a cardiology consultation. It details the patient information, referring physician, rendering provider, and the pre-authorization obtained from the insurance company, including the specific CPT codes for the services rendered.
Information used to fill out the document:
- Patient Name: Jane A. Smith
- Patient DOB: 05/20/1975
- Insurance Provider: HealthGuard Inc.
- Member ID: JSMITH75
- Referring Physician: Dr. Robert Brown, NPI: 1234567890
- Rendering Provider: Dr. Emily White, NPI: 0987654321
- Date of Encounter: 03/10/2026
- Authorization Request Date: 02/25/2026
- Authorization Number: HG2026-C4589
- Authorization Status: Approved
- Effective/Expiration Dates: 03/01/2026 - 03/31/2026
- Primary Diagnosis Code (ICD-10): R07.9 (Unspecified chest pain)
- Authorized Service (CPT Code 1): 99204 (New patient office visit)
- Authorized Service (CPT Code 2): 93000 (Electrocardiogram, routine)
- Completed By: Sarah Davis, Medical Biller
- Date Completed: 03/11/2026
What this filled form sample shows:
- Clear documentation of patient demographic and insurance information.
- Includes both referring and rendering provider details with NPI numbers.
- Tracks the full lifecycle of the pre-authorization process, from request date to approval number.
- Specifies the exact authorized services (CPT codes) and the medical necessity via the diagnosis code (ICD-10).
Form specifications and details:
| Use Case: | Specialist consultation requiring insurance pre-authorization |
| Industry: | Healthcare Administration / Medical Billing |
| Purpose: | To track patient encounters and ensure services rendered have been pre-authorized by the payer to prevent claim denials. |
Created: February 25, 2026 05:50 PM
