G = RELATED SERVICE DELIVERED IN GROUP P = PRESENT AT CB PROGRAM/THERAPIES U = UNAUTHORIZED ABSENCE FROM CB PROGRAM/THERAPIES
I = RELATED SERVICE DELIVERED 1:1 A = AUTHORIZED ABSENCE FROM CB PROGRAM/THERAPIES S = STAFF/CONFERENCE DAY W = WEATHER CLOSING
SERVICES
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PROGRAM ATTENDANCE
SPEECH THERAPY
OCCUPATIONAL THERAPY
PHYSICAL THERAPY
SOCIAL WORK/PSYCHOLOGICAL
OTHER RELATED SERVICE - SPECIFY
Signatures (with credentials) needed for all Center Based services:
SPEECH:
CHILD'S NAME (Last, First) Date of Birth
date of first co-vist with SLP
if
required)
CLAIM TOTAL
$
TSHH/CFY
Occupational TherapistSpecial Educ. Teacher
Psych/CSW
Physical Therapist
SLP
1:1 AIDE
PROGRAM DIRECTOR
1:1 aide
CENTER BASED ATTENDANCE AND THERAPY REPORT
CPSE SERVICES ONLY
# days of
attendance
ICD - 9 Code
USE ONLY THE LETTERS PROVIDED IN THIS KEY
Month/YearAGENCY
I certify that on the dates above, the above named child received
the services noted and that documentation exists and is
maintained on file verifying the delivery of said services in
accordance with all relevant Federal, State and Local Laws and
Regulations governing the Medicaid process.
9.10
Do not alter Essex County Forms they have been designed to meet State and Federal requirements.
