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
(Group, Individual,
Services / Evaluation
Recommended
OT/PT SIGNATURE
IEP REVIEW
INITIAL OBSERVATION -
Face to Face with Child
FIRST QTR REVIEW
Meeting
Meeting
Meeting
2nd OBSERVATION -
Face to Face with Child
SECOND QTR REVIEW
Meeting
Meeting
Meeting
3rd OBSERVATION -
Face to Face with Child
THIRD QTR REVIEW
Meeting
Meeting
Meeting
4th OBSERVATION -
Face to Face with Child
FOURTH QTR REVIEW
Meeting
Meeting
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
Meeting
Meeting
2nd OBSERVATION - Face to
Face with Child
SECOND QTR REVIEW
Meeting
Meeting
Meeting
3rd OBSERVATION - Face to
Face with Child
THIRD QTR REVIEW
Meeting
Meeting
Meeting
4th OBSERVATION - Face to
Face with Child
FOURTH QTR REVIEW
Meeting
Meeting
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
Meeting
Meeting
2nd OBSERVATION - Face to
Face with Child
SECOND QTR REVIEW
Meeting
Meeting
Meeting
3rd OBSERVATION - Face to
Face with Child
THIRD QTR REVIEW
Meeting
Meeting
Meeting
4th OBSERVATION - Face to
Face with Child
FOURTH QTR REVIEW
Meeting
Meeting
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
Meeting
Meeting
2nd OBSERVATION - Face to
Face with Child
SECOND QTR REVIEW
Meeting
Meeting
Meeting
3rd OBSERVATION - Face to
Face with Child
THIRD QTR REVIEW
Meeting
Meeting
Meeting
4th OBSERVATION - Face to
Face with Child
FOURTH QTR REVIEW
Meeting
Meeting
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
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