Progress Note/ Billing Form Page 2
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2Name: ____________________________________ MRN: ________________
2.
Focus of Activity:
(Intervention and Response to Intervention, what did you do? What is the consumer’s response?)
3.
Plan
(e.g. Coordination of Care, Referrals, Follow-up) Specify what the consumer/family/providers are to do.
____________________________________
_____________________
____________
Signature/License/Job Title
Printed Name
Date
____________________________________
________________
Co-Signature/License (if applicable)
Date
______________
Data Entry
Clerk Initials
MHC017-9 (Rev 05-2017) Progress Note/Billing Form
Page 2 of 2
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Parent category: Medical