Municipal Medicaid Service Documentation Form School District Name/Provider #: Service Period, Year XXX School District: Provider # 1234567 August, 2002 Student Name: D.O.B. Jane Doe 08/28/88 Student Medicaid/ID # OR other child specific identifier 123-45-6789 Individual (I) Date Activity/Procedure Note Service time or Group (G) 8/5/02 High kneeling emphasizing control of movement to stance, skipping, and abdominal stren 30 min. I G 8/7/02 Scooter boards, balance activities on one foot and balance beam walking 30 min. I G 8/9/02 Skipping, obstacle course and upper extremity reaching in prone with fine motor manipula 30 min. I G 8/12/02 child absent I G 8/14/02 I G 8/16/02 I G 8/19/02 I G Provider's Signature Supervising Professional's Signature (Required for Registered Physical Therapist services provided "under the direction of") Title Date
Municipal Medicaid Service Documentation Form School District Name/Provider #: Service Period, Year XXX School District: Provider # 1234567 August, 2002 Student Name: D.O.B. Jane Doe 08/28/88 Student Medicaid/ID # OR other child specific identifier 123-45-6789 Date Activity/Procedure Note Individual (I) or Group (G) Service time 8/5/02 High kneeling emphasizing control of movement to stance, skipping, and abdominal stren I G 30 min. 8/7/02 Scooter boards, balance activities on one foot and balance beam walking I G 30 min. 8/9/02 Skipping, obstacle course and upper extremity reaching in prone with fine motor manipula I G 30 min. 8/12/02 child absent I G 8/14/02 I G 8/16/02 I G 8/19/02 I G Provider's Signature Supervising Professional's Signature (Required for Registered Physical Therapist services provided "under the direction of") Title Date
charter-school-training-p1-10-13-05.docx