Form Dmas-355 - Virginia Treatment Referral Information - Department Of Medical Assistance Services
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2EPSDT SPECIALIZED SERVICES
TREATMENT REFERRAL INFORMATION FORM
Virginia Department of Medical Assistance Services
Early and Periodic Screening Diagnosis and Treatment Services
This form must be completed by a physician or nurse practitioner based on health
conditions observed during the most recent EPSDT screening.
Patient Name
Patient Medicaid ID
Attending Physician NPI
Attending Physician Telephone Number
Fax completed form to: ----------------------------
For questions about EPSDT email
epsdt@dmas.virginia.gov
Service Requested
CPT/HCPCS/Rev Code(s):
Intensive ABA Services
H2033
Describe Medical Necessity/Selection Criteria specific to the affected health condition:
Describe recent treatment related to this health condition:
Recommended Treatment Services, Amount Frequency and Discharge Criteria:
1)
Evaluation and medication management recommendation:
2)
OT and Speech evaluation/recommendations:
DMAS‐355
9/10/2008
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Parent category: Medical