Fill - Free fillable Preschool Medicaid Providers Claims For Related Services (Monroe-Woodbury Central School District) PDF form

MEDICAID

MEDICAL ASSISTANCE CLAIMS FOR

RELATED SERVICES

Rev 08-18 1

CERTIFICATION

OF

OCCUPATIONAL AND PHYSICAL THERAPY

UNDER THE DIRECTION AND ACCESSIBILITY

School District/Agency ___________________________________________________________________

I, _____________________, licensed ⁯ Occupational Therapist or ⁯ Physical Therapist with current license

number __________ certify that I am providing direction to the following Occupational Therapy Assistant or

Physical Therapy Assistant for the ______ - ______ school year:

Child’s Name: ________________________________________ DOB: _____________________________

Name of OTA/PTA License #

____________________________________

___________________________________

I am

providing under the direction and accessibility in the following manner:

• Participate in the development of the child’s IEP program, signing and dating the treatment plan

• Monitor the mandated delivery of OT services;

• Be readily available to the OTA/PTA for assistance and consultation, thru phone, email or fax;

• Perform an initial face to face contact with each student served by the OTA/PTA I am supervising and

periodically observe the OTA with each student in the provision of services;

• Review periodic progress notes prepared by the OTA/PTA, consult with the OTA/PTA thru regular monthly

meetings and make recommendations, as appropriate; and

• Review service sheets used for Medicaid billing.

I w

ill keep the appropriate records documenting that “under the direction of “activities have occurred (i.e.

telephone logs, minutes of meetings, minutes of observations etc.)

_____________________________________ __________

Signature of Licensed Occupational/Physical Therapist Date

click to sign

signature

click to edit

Rev 08-18 2

OCCUPATIONAL / PHYSICAL THERAPY “UNDER THE DIRECTION OF” LOG

CHILD NAME _______________________________________

SCHOOL YEAR _______________

AGENCY_________________________

OT/PT SERVICES MANDATED __________________

ASSIGNED OTA/PTA ______________________________________ LICENSE # _______________________

SUPERVISING OT/PT _____________________________________ LICENSE # ________________________

I will keep the appropriate records documenting that the supervision services have occurred (i.e. telephone logs, minutes of

meetings, minutes of observations, initial and subsequent periodic face to face contacts with each student and OTA/PTA)

ACTIVITY

Meeting Date

Type of Meeting

(Group, Individual,

Telephone Etc.)

Services / Evaluation

Recommended

OT/PT SIGNATURE

IEP REVIEW

INITIAL OBSERVATION -

Face to Face with Child

FIRST QTR REVIEW

Meeting

2nd OBSERVATION -

Face to Face with Child

SECOND QTR REVIEW

Meeting

3rd OBSERVATION -

Face to Face with Child

THIRD QTR REVIEW

Meeting

4th OBSERVATION -

Face to Face with Child

FOURTH QTR REVIEW

Meeting

NOTE: The supervising OT/PT MUST provide an initial (within first 2 weeks) and subsequent periodic face to face contact for each student being

serviced by an OTA/PTA.

The PT must have on file the manner in which he/she has provided direction to the PTA for each and every child being

serviced. (One PT can not supervise more than four (4) PTA, per Article 136, section 3738 a.)

The OT must have on file the manner in which he/she has provided “under the direction of” to the OTA for each and

every child being serviced. The supervision must be direct supervision.

Rev 08-18 3

Instructions for Psychological Counseling and Psychological Counseling requiring

“Under the Supervision of”

Psychological Counseling Psychological counseling services may only be provided by a professional

whose credentials are comparable to those of providers who are able to provide psychological counseling

services in the community.

A. Services may be provided by:

• NYS licensed and registered Psychiatrist

• NYS licensed and registered Psychologist

• NYS licensed Clinical Social Worker – LCSW

• NYS licensed Master Social Worker – LMSW – “Under the Supervision of” a

NYS Licensed Psychiatrist, Psychologist or LCSW

Psychological Counseling requiring “Under the Supervision of”

A. The LMSW apprises the Supervisor of the diagnosis and treatment for each child. The cases are

discussed and supervisor provides oversight and guidance in diagnosing and treating child. The

Supervisor regularly reviews and evaluates the professional work of the LMSW.

B. The Supervisor provides at least one hour per week or two hours every other week of in person

individual or group clinical supervision provided that at least two hours per month shall be

individual clinical supervision.

C. The Supervisor must complete a Certification of Supervision for each LMSW being supervised.

An “Under the Supervision of” (USO) log must be used to record direct supervision of LMSW.

Note that it is child specific and must be prepared for each child. Keep all written documentation

of such supervision, including Certification and USO Log. (See Psychological Counseling “Under

the Supervision of” section for detailed instructions.)

Rev 08-18 4

CERTIFICATION

OF

PSYCHOLOGICAL COUNSELING

UNDER THE SUPERVISION AND ACCESSIBILITY

I, ___________________________, Psychiatrist, Psychologist or LCSW, with current license number

_____________________ certify that I am providing "Under the Supervision of" services to the following Licensed

Master Social Worker (LMSW) for the _________ - _________ school year:

Child’s Name: ________________________________________ DOB: __________________

Name of LMSW License Number

____________________________________

I am providing accessibility to the Licensed Master Social Worker in the following

manner:

_________________________________________________________________________

I will keep the appropriate records documenting that the "Under the Supervision of”

activities have occurred (i.e. telephone logs, minutes of meetings, minutes of observations,

initial and subsequent periodic face to face contacts with each student etc.)

_________________________________ ____________

Signature of Supervisor and Title Date

Rev 08-18 5

Psychological Counseling "Under the Supervision of" LOG

CHILD NAME _________________________________________

SCHOOL YEAR _______________

PSYCHOLOGICAL COUNSELING MANDATED ________________________________________

ASSIGNED LMSW ______________________________________ LICENSE # ___________________

SUPERVISOR _____________________________________ TITLE & LICENSE # _______________________________

ACTIVITY

Meeting Date

Type of Meeting

(Group, Individual,

Telephone Etc.)

Services / Evaluation

Recommended

SUPERVISOR

SIGNATURE

IEP REVIEW

INITIAL OBSERVATION - Face

to Face with Child

FIRST QTR REVIEW

Meeting

2nd OBSERVATION - Face to

Face with Child

SECOND QTR REVIEW

Meeting

3rd OBSERVATION - Face to

Face with Child

THIRD QTR REVIEW

Meeting

4th OBSERVATION - Face to

Face with Child

FOURTH QTR REVIEW

Meeting

NOTE: The Supervisor MUST provide an initial (within first 2 weeks) and subsequent periodic face to face contact for each

student being serviced by a LMSW "under the supervision of ". The Supervisor MUST have on file the manner in which

he/she has provided supervision to the LMSW for each and every child being serviced.

Rev 08-18 6

CERTIFICATION

OF

SKILLED NURSING SERVICES

UNDER THE DIRECTION AND ACCESSIBILITY

I, ___________________________, Licensed Registered Nurse (RN), with current license number

_____________________ certify that I am providing "Under the Direction of" services to the following

Licensed

Practical Nurse (LPN)

for the _________ - _________ school year:

Child’s Name: ________________________________________ DOB: __________________

Name of LPN License Number

____________________________________

I am providing accessibility to the Licensed Practical Nurse in the following manner:

_________________________________________________________________________

I will keep the appropriate records documenting that the "Under the Direction of”

activities have occurred (i.e. telephone logs, minutes of meetings, minutes of observations,

initial and subsequent periodic face to face contacts with each student etc.)

_________________________________ ____________

Signature of Supervisor and Title Date

Rev 08-18 7

Skilled Nursing Services "Under the Direction of" LOG

CHILD NAME _________________________________________

SCHOOL YEAR _______________

SKILLED NURSING SERVICES MANDATED ________________________________________

ASSIGNED LPN ____________________________________ LICENSE # ___________________

SUPERVISOR _____________________________________ TITLE & LICENSE # _______________________________

ACTIVITY

Meeting Date

Type of Meeting

(Group, Individual,

Telephone Etc.)

Services / Evaluation

Recommended

SUPERVISOR

SIGNATURE

IEP REVIEW

INITIAL OBSERVATION - Face

to Face with Child

FIRST QTR REVIEW

Meeting

2nd OBSERVATION - Face to

Face with Child

SECOND QTR REVIEW

Meeting

3rd OBSERVATION - Face to

Face with Child

THIRD QTR REVIEW

Meeting

4th OBSERVATION - Face to

Face with Child

FOURTH QTR REVIEW

Meeting

NOTE: The Supervisor MUST provide an initial (within first 2 weeks) and subsequent periodic face to face contact for

each student being serviced by an LPN "under the direction of ". The Supervisor MUST

have on file the manner in

which he/she has provided supervision to the LPN for each and every child being serviced.

Rev 08-18 8

CERTIFICATION

OF SPEECH

UNDER THE DIRECTION AND ACCESSIBILITY

I, ___________________________, CCC-SLP, Licensed Speech-Language Pathologist, with current license number

_____________________ and ASHA Certification # _________________ certify that I am providing "Under the

Di

rection of" services to the following Certified Teachers of the Speech and Hearing Handicapped (Therapist) for

the

_________ - _________ school year:

Child’s Name: ________________________________________ DOB: __________________

Name of TSHH Certification Number

____________________________________

I am providing accessibility to the Teachers of the Speech and Hearing Handicapped

in the following manner:

_________________________________________________________________________

I will keep the appropriate records documenting that the "Under the Direction of”

activities have occurred (i.e. telephone logs, minutes of meetings, minutes of observations,

initial and subsequent periodic face to face contacts with each student etc.)

________________________________ ____________________

Signature of Licensed/ASHA Speech/Language Pathologist Date

Rev 08-18 9

SPEECH "Under the Direction of" LOG

CHILD NAME _________________________________________

SCHOOL YEAR _______________

SPEECH SERVICES MANDATED __________________________________________

ASSIGNED TSHH ______________________________________ CERTIFICATION # ___________________

SUPERVISING SLP _____________________________________ LICENSE # _______________ASHA#______________

ACTIVITY

Meeting Date

Type of Meeting

(Group, Individual,

Telephone Etc.)

Services / Evaluation

Recommended

SLP SIGNATURE

IEP REVIEW

INITIAL OBSERVATION - Face

to Face with Child

FIRST QTR REVIEW

Meeting

2nd OBSERVATION - Face to

Face with Child

SECOND QTR REVIEW

Meeting

3rd OBSERVATION - Face to

Face with Child

THIRD QTR REVIEW

Meeting

4th OBSERVATION - Face to

Face with Child

FOURTH QTR REVIEW

Meeting

NOTE: The supervising SLP MUST provide an initial (within first 2 weeks) and subsequent periodic face to face contact for

each student being serviced by a TSHH "under the direction of ". The SLP must have on file the manner in which he/she has

provided supervision to the TSHH for each and every child being serviced

Rev 08-18 10

INSERT PROVIDER NAME

ADDRESS

PHONE #

Speech Referral / Recommendation for Evaluation / Services

A Speech and Language referral for an evaluation and / or services is recommended in accordance

with the request by the Committee on Pre-School Special Education.

Services, when provided, will be in accordance with the Individualized Education Program designed by the

Committee.

Student Name: _______________________________Date of Birth: ______________________________

School District: _______________________________IEP Dates: _______________________________

mm/dd/yyyy – mm/dd/yyyy

Frequency & Duration of Services: ______________________ (Circle one) Individual / Group

DIAGNOSIS / ICD10 Code: ________________

Pur

pose of Treatment or Evaluation (CPT Code):

____________________________________

__________________________________ ____________________________________________

(Please Print SLP Name) Signature

(must be a NYS Licensed Speech Pathologist/ASHA Certified

)

LICENSE NUMBER: __________________ DATE SIGNED: _______________________________

ASHA CERTIFICATION # _________________ EXPIRES________________ NPI #: _________________

Note: Medicaid requires that speech evaluations and services be recommended by a Licensed Speech Pathologist, Physician,

Physician’s Assistant or Nurse Practitioner prior to or on the date of the evaluation or the start of services.

Rev 08-18 11

INS

ERT PROVIDER/AGENCY LETTERHEAD

SCHOOL YEAR ________________

Dear Parents/Guardians,

In order for ___________INSERT AGENCY/Provider______________ to provide related services to your

child, including nursing, occupational, physical and/or speech therapy, NY State laws require us to collect a

current prescription for the school year of __________for each related service that your district has approved

for your child. As per NYS Preschool Supportive Health Services Program, all scripts must contain the

information stated below. We apologize to those parents who have already secured prescriptions prior to this

regulation, but the prescription without the information is not valid.

It is required that you obtain a prescription that includes the following information:

√ Your child’s name clearly written

√ School year __________________

√ Service to be provided (OT, PT, or ST) submit a separate Rx to acknowledge each service

√ ICD10 code / Diagnosis

√ Original signature of the doctor required – Stamped signature will NOT be accepted

√ License number or NPI#

√ YOU DO NOT NEED – “per IEP” or frequency and duration on prescription

For your convenience, we have enclosed a form that your doctor may wish to use to authorize your child’s

school based related services.

Mail your prescription to:

Agency Address

Rev 08-18 12

PRESCRIPTION FOR PRESCHOOL BASED RELATED SERVICES

(A SEPARATE PRESCRIPTION IS REQUIRED FOR EACH SERVICE)

Student’s Name: ________________________________DOB: ____________________________

District: _______________________________________School: ___________________________

The child named above has been recommended for the following service by his/her school district:

Service/Therapy

(Please check one)

Frequency & Duration

Example: 2 days/week x 60 minu

tes

IEP Dates

mm/dd/yyyy – mm/dd/yyyy

OT PT ST *NU

* In addition to the prescription a specific Dr.’s order with detailed instructions is required.

ICD10 Code/Diagnosis/Purpose of Treatment

Physician/Physician’s Assistant/Nurse Practitioner Information (please print or use stamp):

Name:

Address:

Phone Number:

License Number / NPI #:

__________________

Physician/Physician’s Assistant/Nurse Practitioner

Date

(Must be original signature)

Rev 08-18 13

ESSEX COUNTY

DEPARTMENT OF HEALTH

CHILDREN WITH SPECIAL NEEDS

Preschool Special Education Program

132 Water St. PO Box 217, Elizabethtown NY, 12932-0217

MEDICAL REFERRAL (Prescription)

Based on a review of the child’s records, I am referring this child for the following evaluation(s):

Student’s Name: DOB: ___________

District: School: ___________

Type Of Evaluation

(Please check all that apply)

Audiological Neurological Orthopedic Psychiatric

Occupational Therapy Physical Therapy Other ________________

ICD10 code/Diagnosis/Purpose of Evaluation

Physician/Physician’s Assistant/Nurse Practitioner Information (please print or use stamp):

Name:

Address:

Phone Number:

License Number / NPI #:

__ _____

Signature of Physician/Physician’s Assistant/Nurse Practitioner Date

(Must be original signature)

____________________________________________________________________________________________________

Phone: (518) 873-3500 | Unit Fax: (518) 873-3863 | After Hours Emergency 1-888-270-7249

132 Water Street | PO Box 217 | Elizabethtown, NY 12932 | www.co.essex.ny.us/Health

Director of Public Health- Linda Beers, MPH

Children’s Services COORDINATOR-Lucianna Celotti, BA

Dear Parent/ Guardian of _______________________:

This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance

Program for special education and related services that are on your child's individualized

education program (IEP).

This consent allows the Municipality to bill for covered health-related services and to

release information to the Municipality’s Medicaid Billing Agent for that purpose.

I, _______________________________________________ as the parent/guardian of

____________________________________________,

(Print child’s name)

have received a written notification from the school district that explains my federal

rights regarding the use of public benefits or insurance to pay for certain special

education and related services.

I understand and agree that the school district may access Medicaid to pay for special

education and related services provided to my child.

I understand that:

 Providing consent will not impact my child’s/my Medicaid coverage;

 Upon request, I may review copies of records disclosed pursuant to this

authorization;

 Services listed in my child’s IEP must be provided at no cost to me whether or not

I give consent to bill Medicaid;

 I have the right to withdraw consent at any time; and

 The school district must give me annual written notification of my rights regarding

this consent.

I also give my consent for the Municipality to release the following records/information

about my child to the State’s Medicaid Agency for the purpose of billing for special

education and related services that are in my child’s IEP. The following records will be

shared.

Rev 08-18 15

2

I give my consent voluntarily and understand that I may withdraw my consent at any time. I

also understand that my child’s right to receive special education and related services is in no

way dependent on my granting consent and that, regardless of my decision to provide this

consent, all the required services in my child’s IEP will be provided to my child at no cost to

me.

Parent/Guardian Name and Signature:

_______________________________

Signature

_______________________

Print Name

________________________

Date

Does your child have Medicaid: YES or NO (circle one)

If Yes please indicate CIN:________________________________

Records to be shared (such as records or information about services your child receives)

IEP

Written Order / Referral

Evaluation Reports

Session Notes

Immunization and current Physical (Within one year)

Special Transportation Log

Other Personally Identifiable information

Any other specific records pertaining to the child’s services or program

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