Client ADMIN ONLY Charting

Client Info

Client First Name *

Client Last Name *

Phone *

Email *

Client DOB *

Street Address

City

State

Country

Country

Postal Code

Primary Insurance

Primary Insurance ID

Secondary Insurance (if applicable):

Subscriber Name/DOB (if different from client):

Secondary Insurance ID

Secondary Insurance Subscriber Name/DOB

Medical Record

Last Menstrual Period: *

First pregnancy? *

Yes

No

Date Admitted *

Birth *

Discharged *

Location For Service: OHSU

Which visit is this: *

PN 1

PN 2

Birth

PP 1

PP 2

No Show

Flex visits (same as private pay)

ADMIN

PN #1 Date and Location

PN Services Provided Visit 1

intake

comfort measures

pregnancy resources

emotional support

advocacy

other: (write in answer below)

PN #2 Date and Location

PN Services Provided Visit 2

intake

comfort measures

pregnancy resources

emotional support

advocacy

other: (write in answer)

PP #1 Date and Location

PP Services Provided Visit #1

priorities

comfort measures

emotional support

advocacy

resources

other: (write in answer)

Other PP #1

PP #2 Date and Location

PP Services Provided Visit 2

priorities

comfort measures

emotional support

advocacy

resources

other: (write in answer)

Other PP #2

Additional Notes about Visit Including Flex Visit

The following is an authorization on the claims form. Please review and sign.

Date *

Today's Billing For:

Global (2PN, Birth, 2PP)

Flex Visits

Doula Name *

Admin Name *

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