This form contains 122 fields organized into 33 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Appointment Info
Appointment Time	Time	Enter the scheduled appointment time for the patient as shown on the chart.
Initial	Checkbox	Check this box when the appointment is the patient's initial visit (first visit for this episode of care).
Follow-Up	Checkbox	Check this box when the appointment is a follow-up visit rather than the initial visit.
Last Seen Date	Date	Enter the date the patient was last seen by a provider prior to this visit. Fill only if 'Follow-Up' is 'Yes'.
TOC from Dr.	Checkbox	Check this box when the appointment is a transition of care (TOC) referral or transfer from another doctor and you want to note the referring physician.
TOC From Physician	Text	Enter the name of the physician who transferred care or referred the patient (TOC = Transfer of Care). Fill only if 'TOC from Dr.' is 'Yes'.
Authorization Counts (header)
Date Submitted for Authorization	Date	Enter the date this authorization request was submitted for the specified body part/status.
Number Requested	Text	Enter the total number of services or visits requested under this authorization.
Number Approved	Text	Enter the total number of services or visits approved for this authorization.
Number Modified	Text	Enter the total number of services or visits that were modified or adjusted after the original authorization.
Body Part(s)/Status Field
Body Part(s)/Status 1	Text	Enter the body part(s) involved and their current status or authorization note for this line (for example: “Right Knee – Authorized,” “Left Shoulder – Pending,” or a brief status description).
Completion Info
Today's Date	Date	Enter the date when this checklist was completed.
Form Completed By	Text	Enter the full name or identifier of the person who completed this form.
Current Meds Row 1
Row 1 — Current Meds (Medication)	Text	Enter the name of the medication(s) the patient is currently taking for the first medications row, including dose and frequency if known.
Current Meds Row 1 - Need Refill	Checkbox	Check this box when the medication listed on the first Current Meds row requires a refill.
Row 1 — Current Meds (Notes)	Text	Enter any notes related to the medication(s) listed on this row such as refills, special instructions, start/end dates, or clarifying details.
Current Meds Row 2
Current Med Row 2 - Medication	Text	Enter the medication name (and optionally dose and strength) for the second current medication listed.
Row 2 - Need Refill (1)	Checkbox	Check this box when the first medication listed on Current Meds Row 2 requires a refill.
Current Med Row 2 - Notes	Text	Enter any notes related to this medication such as dosing instructions, frequency, prescribing provider, or refill/comments.
Current Meds Row 3
Current Meds Row 3 — Medication Name	Text	Enter the name of the medication for the third current-medication row (brand or generic) as it should appear in the patient chart.
Current Meds Row 3 - Need Refill	Checkbox	Check this box when the medication listed on the third Current Meds row requires a refill.
Current Meds Row 3 — Notes / Dosage / Instructions	Text	Enter any additional details for the medication in row 3 such as dose, frequency, route, special instructions, or brief notes for the chart.
Current Meds Row 4
Current Meds Row 4 - Medication	Text	Enter the name, dose and any brief prescription details of the fourth current medication the patient is taking (e.g., medication name and strength).
Current Meds Row 4 - Need Refill	Checkbox	Check this box when the medication listed on the fourth Current Meds row requires a refill.
Current Meds Row 4 - Notes	Text	Enter any additional notes about the fourth medication such as directions, refills, prescribing provider, start date, or relevant comments.
Dictation & Report
Initial Dictation Complete: Yes	Checkbox	Check this box when the patient's initial dictation has been completed and submitted.
Initial Dictation Complete: No	Checkbox	Check this box when the patient's initial dictation has not been completed.
Report in File: Yes	Checkbox	Check this box when the dictated report is present in the patient's file.
Report in File: No	Checkbox	Check this box when the dictated report is not present in the patient's file.
General
Body Part(s)	Text
Body Part(s) 2	Text
Grip and Girth Checks
Grips? Yes	Checkbox	Check this box if the patient demonstrated adequate hand grip strength during the exam (grip test performed and normal/acceptable).
Grips? No	Checkbox	Check this box if the patient did not demonstrate adequate hand grip strength during the exam or the grip test was abnormal/absent.
Girths? Yes	Checkbox	Check this box if girth (circumference) measurements were performed and recorded for the affected area(s).
Girths? No	Checkbox	Check this box if girth (circumference) measurements were not performed.
Imaging Header
Date Submitted for Authorization	Date	Enter the date the imaging authorization request was submitted.
Body Part(s)	Text	Enter the anatomical body part(s) for which the imaging study authorization is being requested (e.g., left knee, cervical spine).
Imaging Row 1 (MRI)
Row 1 (MRI) - Rx Date	Date	Enter the prescription/authorization date for the MRI service for Imaging Row 1.
MRI (Row 1) - Authorized	Checkbox	Check this box when the MRI authorization request has been approved/authorized.
MRI (Row 1) - Denied	Checkbox	Check this box when the MRI authorization request has been denied.
MRI (Row 1) - Report in CB? Yes	Checkbox	Check this box when the MRI report is present and filed in the CB (i.e., the chart/binder) indicating 'Yes'.
Imaging Row 2 (CT)
Imaging Row 2 — CT Rx Date	Date	Enter the prescription/authorization date for the CT scan in this row.
CT: Authorized	Checkbox	Check this box when the CT study has been approved/authorized for the patient.
CT: Denied	Checkbox	Check this box when the CT study request was denied and authorization was not granted.
CT: Report in CB? Yes	Checkbox	Check this box when the CT report has been entered into/available in the CB (chart/building) system (answering 'Yes').
Imaging Row 3 (EMG)
EMG (Row 3) Rx Date	Date	Enter the prescription/authorization date for the EMG study in row 3.
Imaging Row 3 (EMG) - Authorized	Checkbox	Check this box when the EMG (row 3) exam/request has been authorized.
Imaging Row 3 (EMG) - Denied	Checkbox	Check this box when the EMG (row 3) exam/request has been denied.
Imaging Row 3 (EMG) - Report in CB? Yes	Checkbox	Check this box when the EMG (row 3) report has been placed in the chart/CB (confirming the report is on file).
Medical Records
Med Recs in File - N/A	Checkbox	Check this box when medical records are not applicable or not required for this case.
Med Recs in File - Yes	Checkbox	Check this box when the patient's medical records are already in the chart/file.
Med Recs in File - Date Requested	Checkbox	Check this box when you are recording the date on which medical records were requested (enter the date in the adjacent field).
Date Requested (Med Records)	Date	Enter the date the medical records were requested for this chart.
Med Recs in File - Status	Checkbox	Check this box when you are entering or updating the current status of the medical records (e.g., pending, received) in the adjacent status field.
Med Records Status	Text	Enter the current status or status code of the medical records request (for example: Pending, Received, Denied, or a short numeric code).
Medication Summary
Meds: Dispensed	Checkbox	Check this box when the listed medication was physically dispensed to the patient.
Meds: Rx	Checkbox	Check this box when a prescription (Rx) for the listed medication was written or provided.
Other Medication 1	Text	Enter the name or brief details of any additional medication related to the patient that is not listed in the main Meds section.
Patient Identification
Patient Name	Text	Enter the full legal name of the patient as it appears in the medical record (first and last name, and middle initial if used).
Account Number	Text	Enter the patient's account or record number assigned by the facility (include any letters or leading zeros exactly as shown).
M.D. (Attending Physician)	Text	Enter the name or initials of the attending physician (the M.D. responsible for the patient) as used on the chart.
Primary Body Part(s)
Primary Body Part(s)	Text	Enter the primary anatomical body part(s) related to this visit or claim (list sides or multiple parts as needed), for example: "Right knee" or "Left shoulder; Cervical spine".
PTP and Claim Info
PTP - Yes	Checkbox	Check this box if this visit/record is for the patient’s Primary Treating Physician (PTP).
PTP - No	Checkbox	Check this box if this visit/record is not for the patient’s Primary Treating Physician (PTP).
PTP - Co-TX Provider	Checkbox	Check this box if a co-treating provider is involved and enter that provider’s name on the adjacent line.
PTP / Treating Provider	Text	Enter the primary treating provider (PTP) or co-treating provider name responsible for the patient’s care.
Delayed Claim - Yes	Checkbox	Check this box if there is a delayed claim associated with this patient/visit.
Delayed Claim - No	Checkbox	Check this box if there is no delayed claim associated with this patient/visit.
Decision Date	Date	Enter the date the claim decision was made. Fill only if 'Delayed Claim - Yes' is 'Yes'.
Rehab Row 1 (FCE)
Rehab Row 1 (FCE) - Rx Date	Date	Enter the prescription date for the FCE (Functional Capacity Evaluation) associated with Rehab Row 1.
Row 1 FCE - Authorized	Checkbox	Check this box when the FCE (Functional Capacity Evaluation) for Rehab Row 1 has been authorized for the requested body part/date.
Row 1 FCE - Denied	Checkbox	Check this box when the FCE for Rehab Row 1 has been denied for the requested body part/date.
Row 1 FCE - Report in CB? Yes	Checkbox	Check this box when the FCE report for Rehab Row 1 has been entered or is available in the claims database (CB).
Rehab Row 2 (DME)
Rehab Row 2 (DME) Rx Date	Date	Enter the prescription (Rx) date for the durable medical equipment (DME) associated with Rehab Row 2.
Rehab Row 2 (DME) - Authorized	Checkbox	Check this box when the DME (Durable Medical Equipment) request in Rehab Row 2 has been authorized.
Rehab Row 2 (DME) - Denied	Checkbox	Check this box when the DME (Durable Medical Equipment) request in Rehab Row 2 has been denied.
Rehab Row 2 (DME) - Report in CB? Yes	Checkbox	Check this box when the report for the DME entry in Rehab Row 2 is included in the claim binder (i.e., 'Report in CB' is yes).
Rehab Row 3 (Other)
Rehab Row 3 (Other) - Rx Date	Date	Enter the prescription or authorization date for the 'Other' rehab service listed in Rehab Row 3.
Rehab Row 3 (Other) - Authorized	Checkbox	Check this box when the 'Other' rehab service on Row 3 has been approved/authorized for the patient.
Rehab Row 3 (Other) - Denied	Checkbox	Check this box when the 'Other' rehab service on Row 3 has been denied and authorization was not granted.
Rehab Row 3 (Other) - Report in CB? Yes	Checkbox	Check this box when a report for the 'Other' rehab service on Row 3 should be filed in the chart board (CB) or marked as reported.
Rehab/Equipment Header
Date Submitted for Authorization	Date	Enter the date the authorization for this rehab/equipment request was submitted.
Body Part(s)	Text	Enter the anatomical body part(s) associated with this rehab/equipment authorization (for example: Right shoulder, L lumbar spine, bilateral knees).
Status - Section 1
Section 1 Status	Text	Enter the current status or short status note for Section 1 (e.g., Authorized, Denied, Pending, or a brief explanation of the case status).
Status - Section 2
Section 2 — Status	Text	Enter the current status or brief status note for Section 2 (for example, authorization outcome, case status, or a short progress/update).
Surgery Info
Date Submitted for Authorization	Date	Enter the date the surgery authorization was submitted. Fill only if 'Eval Only', 'Eval & Treat', 'Transfer of Care', 'AOE/COE', 'QME', 'AME', 'IME' is 'Yes' (any).
Post-Op Appointment Date	Date	Enter the scheduled post-operative follow-up appointment date. Fill only if 'Eval Only', 'Eval & Treat', 'Transfer of Care', 'AOE/COE', 'QME', 'AME', 'IME' is 'Yes' (any).
Rx Date	Date	Enter the date the prescription or authorization request (Rx) was issued.
Surgery: Authorized	Checkbox	Check this box when the requested surgery has been approved/authorized for this patient (use on the Surgery row next to Rx Date and Date of Sx).
Surgery: Denied	Checkbox	Check this box when the requested surgery has been denied for this patient (use on the Surgery row next to Rx Date and Date of Sx).
Date of Surgery	Date	Enter the date the surgery (Sx) was performed.
Days Post-Op (Days P-OP)	Text	Enter the number of days post-operative (days since surgery) at the time of this entry.
Therapy Row 1 (Physical Therapy)
Therapy Row 1 - Physical Therapy Rx Date	Date	Enter the prescription (Rx) date for the first physical therapy authorization.
Therapy Row 1 (Physical Therapy) - Authorized	Checkbox	Check this box when physical therapy for this authorization request has been approved/authorized.
Therapy Row 1 (Physical Therapy) - Denied	Checkbox	Check this box when physical therapy for this authorization request has been denied.
Therapy Row 1 - Physical Therapy # of Visits Completed	Text	Enter the number of physical therapy visits completed for this authorization as digits (for example: 0, 1, 12).
Therapy Row 2 (Chiro)
Chiro Rx Date (Row 2)	Date	Enter the date the chiropractic prescription/authorization was issued for this therapy row.
Therapy Row 2 (Chiro) - Authorized	Checkbox	Check this box when chiropractic treatment for the second therapy row (Chiro) has been authorized for the patient.
Therapy Row 2 (Chiro) - Denied	Checkbox	Check this box when chiropractic treatment for the second therapy row (Chiro) has been denied for the patient.
Chiro # of Visits Completed (Row 2)	Text	Enter the number of chiropractic visits that have been completed for this authorization (use digits).
Therapy Row 3 (Acupuncture)
Therapy Row 3 - Acupuncture Rx Date	Date	Enter the prescription (Rx) date associated with the acupuncture authorization for this therapy row.
Therapy Row 3 (Acupuncture) - Authorized	Checkbox	Check this box when acupuncture visits have been approved/authorized for this patient (enter RX date and number of visits completed as applicable).
Therapy Row 3 (Acupuncture) - Denied	Checkbox	Check this box when the request for acupuncture visits has been denied for this patient (record denial date and any notes as needed).
Therapy Row 3 - Acupuncture # of Visits Completed	Text	Enter the number of acupuncture visits completed (or otherwise counted) for this authorization row as a numeric value.
Type of Case - PI
Eval & Treat	Checkbox	Check this box when the PI case visit is for evaluation and ongoing treatment during this encounter.
Eval & Co-Treat	Checkbox	Check this box when the PI case visit includes evaluation plus co-treatment with another provider during this encounter.
Consult Only w/ Report	Checkbox	Check this box when the PI case visit is a consultation only and a written report will be provided.
Consult w/ MRI & Report	Checkbox	Check this box when the PI case visit is a consultation that includes review of an MRI and a written report.
Surgical Consult w/ Procedures Performed	Checkbox	Check this box when the PI case involves a surgical consultation during which procedures are performed.
Surgical Consultation w/ Report Only	Checkbox	Check this box when the PI case is a surgical consultation that results only in a report and no procedures are performed.
Type of Case - PVT
PVT: PPO	Checkbox	Check this box when the patient's private insurance type is a PPO.
PVT: HMO	Checkbox	Check this box when the patient's private insurance type is an HMO.
PVT: Cash	Checkbox	Check this box when the patient will pay cash or is self-pay for this visit.
PVT: Other	Checkbox	Check this box when the patient's private insurance type is not listed and specify the type on the provided line.
PVT - Other (specify)	Text	Enter the name or brief description of the private/personal payment type when 'Other' is selected (e.g., specific insurer, self-pay arrangement, or payment source). Fill only if 'PVT: Other' is 'Yes'.
Type of Case - WC
Eval Only	Checkbox	Check this box when the worker's compensation (WC) patient is being evaluated only and will not receive treatment at this visit.
Eval & Treat	Checkbox	Check this box when the WC patient will receive both an evaluation and treatment during this visit.
Transfer of Care	Checkbox	Check this box when the patient's care is being transferred to or from another provider for this WC case.
AOE/COE	Checkbox	Check this box when the visit is for AOE/COE purposes for this WC case.
QME	Checkbox	Check this box when the visit is a Qualified Medical Evaluator (QME) examination for this WC case.
AME	Checkbox	Check this box when the visit is an Agreed Medical Evaluator (AME) examination for this WC case.
IME	Checkbox	Check this box when the visit is an Independent Medical Examination (IME) for this WC case.

Patient Encounter and Authorization Tracking Form Instructions