North Carolina Infant-Toddler Program Service Order Form Purpose: To document the medical necessity for early intervention services. Instructions: The Service Order Form must include an appropriate diagnosis for each service being provided. Fill out the Service Order according to the following requirements and guidance: A physician’s order signed and dated by a physician, PA, or Nurse Practitioner, if the CDSA or provider is providing a specialized therapy service or other service requiring licensure. The physician’s order must precede the service and there must be a separate physician’s order specific to the discipline providing the service. Community Based Rehabilitative Services [CBRS] must be ordered by and under the direction of a physician or licensed practitioner of the healing arts. The service order must specify which level of CBRS is to be provided (i.e. Professional). The signed order must precede the service and must include the prescribing physician’s NPI number, if Medicaid is being billed for the service. Note: If physician’s orders are obtained directly from a medical provider by the Provider of a specialized therapy or CBRS, the use of the Infant-Toddler Program Service Order Form is not required. However, a copy of the physician’s order for each treatment must be given to the CDSA to file in the child’s central record. Disposition: Infant-Toddler Program records, including financial and automated information, must be maintained for a minimum of five years following the child’s third birthday. Records must be archived in accordance with state requirements to ensure their preservation for the required length of time.
North Carolina Infant-Toddler Program Service Order Form Purpose: To document the medical necessity for early intervention services. Instructions: The Service Order Form must include an appropriate diagnosis for each service being provided. Fill out the Service Order according to the following requirements and guidance: A physician’s order signed and dated by a physician, PA, or Nurse Practitioner, if the CDSA or provider is providing a specialized therapy service or other service requiring licensure. The physician’s order must precede the service and there must be a separate physician’s order specific to the discipline providing the service. Community Based Rehabilitative Services [CBRS] must be ordered by and under the direction of a physician or licensed practitioner of the healing arts. The service order must specify which level of CBRS is to be provided (i.e. Professional). The signed order must precede the service and must include the prescribing physician’s NPI number, if Medicaid is being billed for the service. Note: If physician’s orders are obtained directly from a medical provider by the Provider of a specialized therapy or CBRS, the use of the Infant-Toddler Program Service Order Form is not required. However, a copy of the physician’s order for each treatment must be given to the CDSA to file in the child’s central record. Disposition: Infant-Toddler Program records, including financial and automated information, must be maintained for a minimum of five years following the child’s third birthday. Records must be archived in accordance with state requirements to ensure their preservation for the required length of time.
7022ServiceOrderForm.docx