Claim Form Examples | TMHP Family Planning 2017 Claim Form (180.02 KB) FQHC Encounter (T1015) (615.98 KB) FQHC Follow-Up (623.5 KB) Renal Dialysis CMS-1500 Example (231.29 KB) Renal Dialysis Facility CAPD/CCPD (615.59 KB) Renal Dialysis Facility CAPD Training (666.45 KB) Rural Health Clinic Freestanding (Immunization) (589.54 KB) Rural Health Clinic Freestanding (588.62 KB)