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Document No. KENTUCKY LOCAL HEALTH DEPARTMENT Date PATIENT ENCOUNTER FORM AFC CNCT Patient Name LEP Place of Service/Pay CT (A) Index Lab (B-I) Assigned by LED (J) Input Hosp (K) Output Hosp (L) Physician
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Ch-45 rev 07 15 is a specific form used for reporting certain information to the appropriate authorities.
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Entities or individuals specified by the regulating authority are required to file ch-45 rev 07 15.
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Ch-45 rev 07 15 must be filled out according to the instructions provided by the regulating authority.
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The purpose of ch-45 rev 07 15 is to collect specific information for regulatory or compliance purposes.
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