Medicaid Letter To Physician
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1SOUTH BEND COMMUNITY SCHOOL CORPORATION
Special Education Department
215 S. St. Joseph Street, South Bend, IN 46601
Phone: 574-283-8130 FAX: 574-283-8105
Dear Parent:
Federal regulations define Medicaid-covered speech, language and hearing evaluations and therapy s services
that are referred by a physician or licensed practitioner of the healing arts within the scope of his or her practice
under state law. This includes your family doctor, podiatrist, chiropractor or dentist. Because school systems can
receive Medicaid reimbursement for these services, the Indiana Department of Education requires one of the
professionals mentioned above to complete the bottom portion of this letter. It is important to assure you the this
requirement will in no way delay or disrupt corporation procedures under state and federal law that require
parent consent with advance notice for an evaluation, a case conference and services/
It is our hope that your physician or licensed practitioner will complete this form without the need to schedule an
additional appointment for this requirement. Thank you in advance for your cooperation and follow up.
Sincerely,
Speech-language Pathologist or Audiologist
School
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Dear Dr. ______________________________ :
As explained in the letter above, a referral is required in order for students to receive speech, language and/or
hearing evaluatinos and therapy. Please indicate your recommendation for
Student
In my profession opinion this student is in need of:
speech-language evaluation
speech-language therapy (if determined eligible in a case conference)
hearing screening
audiological evaluation
aural rehabilitation following cochlear implant
Please stamp name and location below:
Signature of Licensed Practitioner
Date
Thank you. Please mail or fax this form to the Special Education Office, FAX 574-283-8105, Attn: Chuck Moore
Rev. 10/07
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