FAMILY PLANNING RESUPPLY FORM (BC-1) Purpose To provide a thorough and up-to-date patient medical history to meet program and provider requirements as well as the needs of the client for a family planning supply and counseling office visit. Initiation and Maintenance The Family Planning Resupply Form (BC-1) can be initiated for visits in which the client returns to the LHD for a re-supply and counseling visit for their family planning method according to provider’s orders. Instructions for Completion Use C or D label with the patient’s name, patient ID number and HID/LOC Site. If a label is not accessible, enter the patient’s name, ID number, and the HID/LOC/SITE of site. The top portion of the form is designed to be filled out by the patient. This section is to be reviewed with the patient by a healthcare provider at the time of the visit and Patient signature, healthcare provider signature, and date are required. The Healthcare Provider section contains check boxes designed to aid the provider in meeting program protocols/guidelines and standards for reimbursement. Health Education Educational Handouts Testing performed Medication/Supplies given Referrals made to the patient at the time of the visit. Provider signature, date and RTC Recommendations are required after completion of this section. Information documented in this form does not have to be repeated on the CH-3a Progress Notes. Recommended placement of the BC-1 is in the Patient Management (right side) section of the MR along with the CH3a Progress notes and should be filed in chronological order with the most current data on top. However, if the LHD chooses to place the BC-1 elsewhere in the Medical Record the arrangement should be consistent for all records in each county. - All blanks spaces and sections are to be filled in to meet CCSG program Important guidelines/protocols, coding and billing requirements, clinician discretion, or patient preferences. The healthcare providers will use professional judgment and program requirements to determine what medical information to gather from the client. Leaving blank spaces exposes the health care provider to questions that information may have been in” information or with. “filled “tampered” BC1 Instr. Approved 7/1/2016
FAMILY PLANNING RESUPPLY FORM (BC-1) Purpose To provide a thorough and up-to-date patient medical history to meet program and provider requirements as well as the needs of the client for a family planning supply and counseling office visit. Initiation and Maintenance The Family Planning Resupply Form (BC-1) can be initiated for visits in which the client returns to the LHD for a re-supply and counseling visit for their family planning method according to provider’s orders. Instructions for Completion Use C or D label with the patient’s name, patient ID number and HID/LOC Site. If a label is not accessible, enter the patient’s name, ID number, and the HID/LOC/SITE of site. The top portion of the form is designed to be filled out by the patient. This section is to be reviewed with the patient by a healthcare provider at the time of the visit and Patient signature, healthcare provider signature, and date are required. The Healthcare Provider section contains check boxes designed to aid the provider in meeting program protocols/guidelines and standards for reimbursement. Health Education Educational Handouts Testing performed Medication/Supplies given Referrals made to the patient at the time of the visit. Provider signature, date and RTC Recommendations are required after completion of this section. Information documented in this form does not have to be repeated on the CH-3a Progress Notes. Recommended placement of the BC-1 is in the Patient Management (right side) section of the MR along with the CH3a Progress notes and should be filed in chronological order with the most current data on top. However, if the LHD chooses to place the BC-1 elsewhere in the Medical Record the arrangement should be consistent for all records in each county. Important - All blanks spaces and sections are to be filled in to meet CCSG program guidelines/protocols, coding and billing requirements, clinician discretion, or patient preferences. The healthcare providers will use professional judgment and program requirements to determine what medical information to gather from the client. Leaving blank spaces exposes the health care provider to questions that information may have been “filled in” information or “tampered” with. BC1 Instr. Approved 7/1/2016