The Progressions Companies Inc.
Encounter Form
Employee Name:
Paycheck Site: / Pottstown
Recipient Name:
Insurance:
Authorized Time Period
-
BSC hours per week
Assigned BSC:
MT hours per week
Assigned MT:
TSS hours per week:
School / Home
Camp / Other
Assigned School
Assigned Home
Assigned Camp
Assigned Other
Type of Service Provided (circle one) / BSC BSC-PhD MT TSS-NS TSS-S TSS-Group
Date / Start / End / Total Hrs / Total Units / Daily signatures / Parent/Guardian/Teacher
Recipient 14 years or older / Date Signed / Contact Code
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Total Hours/Units:

I certify that this information on this encounter form is true, correct and accurate. I understand that payment and satisfaction of this claim will be from federal and state funds, and that false claims, statements, documents or concealment of materialmay be prosecuted under applicable federal and state laws.

Type of Service Provided (circle one) / BSC BSC-PhD MT TSS-NS TSS-S TSS-Group
Date / Start / End / Total Hrs / Total Units / Daily signatures / Parent/Guardian/Teacher
Recipient 14 years or older / Date Signed / Contact Code
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Total Hours/Units:
Codes: / Home = H, School = S, Phone = P, Community = C, Treatment Planning = Tx
Camp = CA, Interagency Meeting = ITM, Monthly Mobile = MM, Non Bill =NB, Write Off= WO

PARENT, TEACHER, OTHER CARETAKER OR SERVICE RECIPIENT (IF 14 YEARS OF AGE OR OLDER)

Never sign a blank, pre-dated, post dated or otherwise incomplete encounter form. Always put the date of your signature, even if signing for services that were provided earlier than that date. Signing blank, pre-dated, post-dated or otherwise incomplete encounter forms is a violation of agency policy as well as of state and federal regulations. It may lead to an investigation of Medicare/Medicaid fraud and abuse. In some situations, it may lead to loss of your staff and services.
Please make sure that you are receiving the services authorized for your child. If you have any
questions concerning the services we are providing, or how we are billing for them, please call
me at (610)970-5000 ext.710 / or call our corporate compliance officer, Roger Eppehimerat
1-866-941 4151.
Thank you for the opportunity of working with your child and for your helping us meet the highest standards of service delivery.
Sincerely, f / Heather Grinar, LPC
Pottstown Site Director
Progressions Behavioral Health Services Inc

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Parent/Legal Guardian/Teacher Date

______

Recipient 14+/ Responsible Adult Signature Date

I, THE UNDERSIGNED CERTIFY THAT THIS IS AN ACCURATE RECORD OF MY WORKING TIME DURING THIS PAY PERIOD, AND THAT THESE HOURS WERE PROPERLY VERIFIED BY AN AUTHORIZED REPRESENTATIVE.

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Employee Signature & Degree Date

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Director or Authorized Representative Signature Date

Please give a brief description as to why any services were not provided.

Date / Authorized / Provided / Reason