Encounter Form {MA 91}

DEPARTMENT OF PUBLIC WELFARE OFFICE OF MEDICAL ASSISTANCE PROGRAMS ENCOUNTER FORM PROVIDER NAME PROVIDER NUMBER ADDRESS "My signature certifies that I received a service or item on the date listed below. I understand that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State laws." DATE RECIPIENT NUMBER RECIPIENT'S SIGNATURE I have read and agree with the above statement. American LegalNet, Inc. www.FormsWorkFlow.com MA 91 8/06