Charles County Public Schools s2

Charles County Public Schools Monthly Medicaid Services Record for I&T

Student: Last First MA# Diagnosis Code: Student ID# DOB: Provider: Position: School: Provider’s Signature: Date: Consent Date: # of Sessions: Frequency: Intensity:

Date of Session Progress Notes Must be Attached. Svc. Type of Time No. of Provider Service # Related Service Description Loc. Session Unit(s) Initials

Service Description: Screening, Assessment, Treatment (Specify – Attach Progress Notes), or Other (Specify) Service Location: School/Office = 11, Home = 12 Type of Session: (I) Individual, (G), Group No. of Units: Increments of 15 min = 1 Unit – Maximum of 4 units per day

Providers: Please submit this report to your Medicaid Coordinator by the 5th of each month following service and file a copy in the child’s Individual Unit Folder. If applicable, attach the IFSP Review Consent and Part 4 of the Early Intervention Services Record for any changes and/or when Service Ends.

Revised 8/10