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		PROGRAMS & SERVICES: SPECIAL EDUCATION FINANCE & MEDICAID: MANUAL FOR SCHOOL-BASED HEALTH SERVICES (Updated 9/16/10)     This document is a compilations of informaton about the School-Based Health Services program. The manual provides information on all aspects fo the program, from the state statute that allows schools to bill Medicaid, to instructions and requirements for Medicaid forms and paperwork.     MANUAL FOR SCHOOL-BASED HEALTH SERVICES (Updated 9/16/10)         Chapters, Forms & Sample Forms Downloads in PDF Individual Forms & Sample Form Downloads ONLY   ID Chapter & Documentation (PDF) Word PDF/Excel SAMPLE (PDF) 1 Introduction - - - A Eligibility  - - - B Release of Information    Brochure Only - PDF -   Legal Guardian Letter Word - Sample   Legal Guardian Letter (Consulting Physician) Word - Sample   Release of Information Word - Sample   Release of Information - 18 Year Old Word - -   SRS Blanket Consent Form - PDF - C Physician Authorization   Physician Authorization Form Word - Sample   Physician Authorization Letter Word - - D IEP & Evaluation Claims   IEP Claim Form - Excel Sample   Evaluation Claim Form - Excel Sample E Billable Services  - - - F Provider Documentation    Provider Certification / Agreement / Reassignment of Payment Word - Sample   Case Management Assurance Word - Sample   Developmental & Assistive Therapy Service Documentation Log Word - Sample   Personal Care Service Documentation Log Word - Sample   Personal Care Verification Form   Excel Sample   Related Services Documentation Log Word - Sample   Who Can Make Changes? - PDF - G Level of Care Billing Process    Level of Care Billing Form - Excel Sample (Excel)   Level of Care Rate Sheet (Grid) - PDF - H Out of District Placement    Out-of-District Provider Certification Agreement Word - Sample I PNMI Claims Process   PNMI Claim Form - Excel Sample   PNMI Rates - PDF - J Durable Medical Equipment Process  L Electronic Claims Submission M Remittance Advice (RA)   Remittance Advice Form - - Sample N Adjustments & Recoupments   Paper Claim Form - PDF Sample O Grant Awards - - Sample P State-Placed Student Issues (Updated 9/16/10) Q Records   Confidentiality Pledge Form Word - - R Directories - - -   Acronyms - PDF -   Clerk List - PDF -   T Codes - PDF -           Medicaid Information & Resources Special Education Finance Business Management | Federal Fiscal Services School Finance | Special Education Finance PDF files require the use of Adobe Acrobat Reader. To download a free version of Adobe Acrobat Reader, click on the icon below. View Acrobat tips and information.
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