Service Record – School Based Speech Therapy Billing Form
Service Record – School Based Speech Therapy Billing FormMedicaid NumberLast NameFirst NameWVEIS NumberDate of BirthProvider NameCountySchoolMonth/YearLIST ALL DIAGNOSIS CODES RELATED TO SPEECH1.2.3.4.5.6.Speech Therapy Services: Physician’s authorization on file. Services must be identified on the Plan of Care. If a service is provided via Telehealth add GT modifier to the procedure code.Service DateList Diagnosis Code Number(s)Procedure codeStart TimeEnd TimeUnits/Event_________________________ ___________________ Signature/Credentials Date Page___of___ ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- where questions speech therapy worksheets
- wh questions speech therapy worksheets
- wh questions speech therapy games
- speech therapy who questions activities
- free speech therapy for adults
- free printable speech therapy activities
- who questions speech therapy worksheet
- speech therapy activities for adults
- speech therapy activities for teens
- free speech therapy worksheets
- home infusion therapy billing guidelines
- physical therapy billing code descriptions