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KIDZ THERAPY EARLY INTERVENTION DAILY SESSION NOTESFor services in Nassau County Page ___ of ____ Child’s Name: Date of Birth: / / ICD-10 Code:Authorization # ______________________Service:_____________________________ ____________________ Type (ST, OT, PT, SPED, Family Training, SW, Vision) Frequency & DurationAuthorization Period: / / to / / # of Authorized Sessions: Provider/Agency Name: Provider Name: Professional Title Kidz Therapy Services, PLLC _____________________________________ ____________________________ Agency NPI #: 1730334426 Provider NPI#: License# Location:Service Code (enter in brackets): [ ]P=Service Provided M=Make-up TA=Teacher Absence CA = Child Absence H=Holiday CoV =CoVisit I=IFSP Mtg DATE: / / [ ] IN: _____OUT:______ *Parent/Caregiver Signature:____________________Date: _________586549526670M/U for ___________CPT Codes:00M/U for ___________CPT Codes:Desired Outcome/Goals: Session Content: *Provider Signature/License Initials: _________________________________________________ Date note written: __________________DATE: / / [ ] IN:______OUT:______ *Parent/Caregiver Signature:___________________Date: _________587502033655M/U for ___________CPT Codes:00M/U for ___________CPT Codes:Desired Outcome/Goals: Session Content: *Provider Signature/License Initials: _________________________________________________ Date note written: __________________DATE: / / [ ] IN:______OUT:______ *Parent/Caregiver Signature:___________________Date: _________587692515875M/U for ___________CPT Codes:00M/U for ___________CPT Codes:Desired Outcome/Goals: Session Content: *Provider Signature/License Initials: _________________________________________________ Date note written: __________________DATE: / / [ ] IN:______OUT:______ *Parent/Caregiver Signature:___________________Date: _________587692525400M/U for ___________CPT Codes:00M/U for ___________CPT Codes:Desired Outcome/Goals: Session Content: *Provider Signature/License Initials: _________________________________________________ Date note written: __________________Recommendations for support, education, and guidance for parents: (Complete )_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5/2018Child’s Name: Service Type: ICD10 Code: Page ____ of ____5869940200025M/U for ___________CPT Codes:00M/U for ___________CPT Codes:DATE: / / [ ] IN:______OUT:______ *Parent/Caregiver Signature:____________________Date: _________ Desired Outcome/Goals: Session Content: *Provider Signature/License Initials: _________________________________________________ Date note written: __________________DATE: / / [ ] IN:______OUT:______ *Parent/Caregiver Signature:____________________Date: _________58743857620M/U for ___________CPT Codes:00M/U for ___________CPT Codes:Desired Outcome/Goals: Session Content: *Provider Signature/License Initials: _________________________________________________ Date note written: __________________DATE: / / [ ] IN:______OUT:______ *Parent/Caregiver Signature:____________________Date: _________587692525400M/U for ___________CPT Codes:00M/U for ___________CPT Codes:Desired Outcome/Goals: Session Content: *Provider Signature/License Initials: _________________________________________________ Date note written: __________________DATE: / / [ ] IN:______OUT:______ *Parent/Caregiver Signature:____________________Date: _________586549526035M/U for ___________CPT Codes:00M/U for ___________CPT Codes:Desired Outcome/Goals: Session Content: *Provider Signature/License Initials: _________________________________________________ Date note written: __________________Recommendations for support, education, and guidance for parents: (Complete) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SPECIFIC CONTACT AND COMMENTS BETWEEN TEAM MEMBERS, DOH, AND OTHERS (Doctors, etc.)DATECODESNOTESCodes: TC: Telephone ContactAV: Agency VisitHV: Home Visit IFSP: Indiv Fam Svc PlanTM: Team Meeting CN: Communications Notebook PC: Teacher/Therapist Consult OC: Other Direct Contact5/2018 ................
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