CCJS - SPEECH-LANGUAGE / OCCUPATIONAL THERAPY / PHYSICAL THERAPY SERVICES REFERRAL AND AUTHORIZATION

Clinton County Joint Services
SPEECH-LANGUAGE / OCCUPATIONAL THERAPY / PHYSICAL THERAPY SERVICES REFERRAL AND AUTHORIZATION
Referral and Authorization for Evaluation, Treatment Services, and/or Other Medicaid-covered Services Must be Completed by a Licensed Professional in Accordance with Current State and Federal Rules. Additionally, the Ordering/Referring Physician's or HSPP's NPI # MUST be Documented if Not a School Employee or School-based Contractor.
Student Name*
Date of Birth*

MonthDayYear
Date
Speech Language

EvaluationTreatment ServicesOther
Evaluation
Treatment Services
Other
Occupational Therapy

EvaluationTreatment ServicesOther
Evaluation
Treatment Services
Other
Physical Therapy

EvaluationTreatment ServicesOther
Evaluation
Treatment Services
Other
Additional Comments
Authorized Signature*

Clear
Print Name & Title*
National Provider Identifier (NPI) #:*
Date*

MonthDayYear
Date
Should be Empty:

Clinton County Joint Services