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Physical Exam Form - The Overlake School - school physical exam cpt

Physical Exam Form - The Overlake School-school physical exam cpt

The Overlake School Physical Examination (Medical Form 20-21)
e: Date of Birth: / /
To be completed by examining healthcare provider. A valid physical is required for athletics participation,
upon enrollment, and upon entering 9th Grade. Valid for 13 months from the date of the exam.
Height:________ Weight: ______ Pulse: ________ BP: ____/ _____
Vision R: 20/_____ Vision L 20/ _____ Corrected Y/N Contacts/ Glasses
Pupils Equal / Unequal
MEDICAL Normal Abnormal Finding / Recommendation Initials
Appearance / skin
Lymph Nodes
Head / Neck
Upper Extremity
Lower Extremity
ROM / Flexibility
I conducted a physical examination of the above named student. Based on my findings, the student is:
[ ] Cleared - all sports/PE [ ] Cleared - non-contact sports only
[ ] Cleared after completing evaluation / rehabilitation for: _____________________________________
[ ] Not cleared for (Reason/Recommendations):_____________________________________________
Name of health care provider ___________________________________ Date of Exam _____________
(please stamp or print)
Address: ____________________________________________________ Phone: _________________
Signature of health care provider___________________________________, MD, DO, ARNP, PA or ND

What does CPT code 99396 include?What does code 99396 mean? 99396 is a billing code which is for: Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures,