Immunisation Encounter Header Form Page 3
ADVERTISEMENT
1
2
3
4Immunisation encounter header form
IM001
D
Date of service
E
Only complete if not provided on each
T
Immunisation encounter form
A
Provider name
I
/
/
L
S
Address
Number of encounter forms
O
Postcode
F
S
E
Declaration by provider who rendered the immunisation services
R
Please supply Medicare provider/ACIR registration
V
number if imprinter not used.
To the best of my knowledge and belief all information provided is true.
I
Medicare provider/ACIR
Giving false or misleading information is a serious offence.
C
registration number
E
Signature of provider who rendered the services
P
R
O
-
V
I
Date
D
E
/
/
R
PROVIDER COPY
IM001.1403 (formerly IMMU-1)
XXXXXXX
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical