Encounter Form Samples

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Updated: 01/08/2021
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The below templates for Encounter Forms, also known as paper superbills or fee tickets, are available for use within the Kareo Desktop Application (PM). Click on a thumbnail image or title to view a sample of how the encounter form will print. Once you decide on the ones you want to use, add them within Kareo.

Thumbnail	Description
	One Page A one-page form with solid grid lines. Procedures on top in three columns. Diagnoses are below in three columns and the last column has space for a physician's signature.
	One Page (Large Font) A one-page form with solid grid lines just like "One Page", but the fonts used for the procedures and diagnoses are larger, touching the grid lines. Procedures on top in three columns. Diagnoses are below in three columns and the last column has space for a physician's signature.
	Two Page — Page 1 , Page 2 A two-page form with solid grid lines. The first page contains procedures in three columns. The second page contains diagnoses in three columns, and a footer with space for a physician's signature.
	Two Page (First Page Only) This is the first page of the “Two Page” form with solid grid lines. The page contains procedures in three columns. The second page containing diagnoses and footer does not print.
	Two Page Version 2 — Page 1 , Page 2 A two-page form with dotted grid lines. The first page contains procedures in three columns. The second page contains diagnoses in three columns, and a footer with space for a physician's signature.
	Two Page Version 2 (First Page Only) This is the first page of the “Two Page Version 2” form with dotted grid lines. The page contains procedures in four columns. The second page containing diagnoses and footer does not print.
	One Page No Grid Extended This one-page form that is blank with a header. The header contains patient, insurance, appointment, account balance, and payment information.
	One Page Version 2 A one-page form with dotted grid lines. Procedures are on top in four columns. Diagnoses are below in four columns and takes up half the space as the procedures. The footer contains a return schedule box.
	Two Page Four Column Grid — Page 1 , Page 2 A two-page form with dotted grid lines. The first page contains procedures in four columns, and a footer with a return schedule box. The second page contains diagnoses in four columns, and a footer with space for a physician's signature.
	Two Page with Recent Diagnoses — Page 1 , Page 2 A two-page form with dotted grid lines. The first page contains six recent diagnoses for the current patient and case in three columns, followed by procedures arranged in three columns. The second page contains diagnoses in three columns, and a footer with space for a physician's signature.
	1-Page, 3-Column with Recent Diagnoses A one-page form with dotted grid lines. Six recent diagnoses for the current patient and case in three columns at the top, followed by the normal diagnosis list in three columns. Procedures are below in three columns, and the last column of has space for a physician's signature.
	1-Page, 4-Column with Recent Diagnoses A one-page form with dotted grid lines. Eight recent diagnoses for the current patient and case in four columns at the top, followed by the normal diagnosis list in four columns. Procedures are below in four columns and the last column of has space for a physician's signature.
	One Page Four Column A one-page form with solid grid lines. The header contains space for patient account status and a return schedule box. Procedures are on top in four columns. Diagnoses are below in four columns and takes up half the space as the procedures.
	One Page More Diagnoses A one-page form with dotted grid lines. Procedures on top in four columns. Diagnoses are below in four columns and takes up twice the space as the procedures. The footer contains a return schedule box.
	One Page Blank Fourth Columns A one-page form with dotted grid lines. Procedures on top in four columns and takes up twice as much space as diagnoses below in four columns. The last column of procedures and diagnoses is blank with no grid lines to allow for notes. The last column of diagnoses has space for a physician's signature. The footer contains a return schedule box.
	Blank Encounter Form with Header A one-page form that is blank with a header. The header contains patient, insurance, appointment, account activity, and payment information. This form provides flexibility to construct the layout as desired outside of Kareo.
	1-Page, 2-Column Procedures A one-page form with dotted grid lines. Procedures on top in two columns. Diagnoses are below in four columns and takes up half the space as the procedures. The footer contains a return schedule box.
	One Page Equal Spacing A one-page form with solid grid lines. Procedures are on top in four columns. Diagnoses are below in four columns and takes up an equal space as the procedures. The header contains space for patient account status and a return schedule box.
	One Page AO A one-page form with solid grid lines and yellow highlighting for headers and footer. Diagnoses on top are in four columns. Procedures are below in four columns and takes up half the space as the diagnoses. The footer contains space for patient's and physician's signatures.
	One Page Three Column A one-page form with solid grid lines. There are nine rows of procedures in three columns on top. Diagnoses are below in three columns and takes up the rest of the page.
	One Page No Grid Lines A one-page form with no grid lines. Procedures are on top in four columns. Diagnoses are below in four columns and takes up an equal space as the procedures.
	Blank Encounter Form with Header Footer A one-page form with a header and footer that is blank in the middle. The header contains patient, insurance, and appointment information. The footer contains account balance, account activity, and payment information. This form gives flexibility to construct the layout as desired outside of Kareo.
	1-Page, No Grid Lines with More Diagnoses A one-page form with no grid lines. There are ten rows of procedures in four columns on top. Diagnoses are below in four columns and takes up twice the space as the procedures.
	One Page DMN A one-page form with no grid lines. Procedures are on top in three columns and contain space for a fee. Diagnoses are below in four columns and are numbered.
	One Page No Grid Lines Version 2 A one-page form with no grid lines. Procedures are on top in four columns. Diagnoses are below in four columns and takes up twice the space as the procedures. The form uses smaller fonts than the "One Page No Grid Lines" form, and can fit more entries in the lists.
	One Page DB A one-page form with no grid lines. Procedures are on top in one wide column that contains spaces for modifiers and fees. Diagnoses are below in two columns.
	One Page No Diagnoses Section A one-page form with solid grid lines. Only lists procedures in three columns and contains space for a fee. The footer has space for a fill-in diagnosis.
	1-Page, 4-Column with 3 Insurances A one-page form with solid grid lines. The header contains a return schedule box, and has space for primary, secondary and tertiary insurance. Procedures take up the vast majority of the page, arranged in four column. Diagnoses are at the bottom of the page in four columns.
	1-Page, Original with More Diagnoses A one-page form with solid grid lines. Procedures on top in three columns. Diagnoses are below in three columns and the last column has space for a physician's signature. This form has slightly more diagnoses than "One Page" form.
	1-Page, 3-Column with Equal Spacing A one-page form with solid grid lines. Procedures on top in three columns. Diagnoses are below in three columns and takes up an equal space as the procedures.
	1-Page, 3-Column with 3 Insurances Big Font A one-page form with solid grid lines. The page header contains a return schedule box, and has space for primary, secondary and tertiary insurance. Procedures take up the vast majority of the page, arranged in three columns. Diagnoses are at the bottom of the page in three columns.
	One Page Four Column Grid A one-page form with dotted grid lines. Procedures take up the vast majority of the page, arranged in four columns. The footer contains a space for notes, a return schedule box and space for a physician's signature.
	One Page Mods and Fees A one-page form with solid grid lines. Procedures take up the vast majority of the page, arranged in two columns, and contains modifiers and fees. Diagnoses are below in three columns and the last column has space for a physician's signature.