Immunisation Encounter Header Form printable pdf download

Immunisation Encounter Header Form

Australian Childhood Immunisation Register

IM001

DO NOT REMOVE COVER SHEET BEFORE IMPRINTING AND PLEASE PRINT CAREFULLY.

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This form is used to record details of the provider.

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If you have a provider or registration card and imprinter you can imprint the card to record your details.

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If you do not have a provider card or imprinter, record your name and provider number or name and

practice address in the space provided.

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If all recorded episodes were administered on the same day, you may choose to write the date of service

on the Immunisation encounter header form (IM001).

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If the recorded episodes were administered on different days, you must write the date of service on each

individual Immunisation encounter form (IM002).

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You can submit up to 99 Immunisation encounter forms under one Immunisation encounter header form.

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Please forward claims to the Australian Childhood Immunisation Register (ACIR) on a weekly basis.

Claim No:

XXXXXXX

IM001.1403 (formerly IMMU-1)

Immunisation Encounter Header Form