West Virginia Medicaid Physician Authorization Form - Department Of Education
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1MEDICAID PHYSICIAN AUTHORIZATION FORM
_______________County Schools
Student’s Full Name _______________________________
Date _________________________
School __________________________________________
Date of Birth __________________
Parent(s)/Guardian(s) ______________________________
Grade ________________________
Address _________________________________________
WVEIS# _____________________
City/State/Zip_____________________________________
Telephone ____________________
Medicaid number: ________________________________________________
Please review and authorize the services that are included on your patient’s Individualized Education Program and
Services Care Plan. Thank you for your assistance.
TO:
Physician’s Name (Please Print)
Address
City/State/Zip
The following services have been included on the student’s Individualized Education Program and Service Care
Plan.
Service included
Diagnosis Codes - ICD – 10
on Individualized
Frequency/
Evaluation
Service
Education Program
Code(s) that justify therapy being
Duration
Reevaluation
and Service Care
provided
Plan
Physical Therapy
Occupational
Therapy
Speech Therapy
Audiology
Psychotherapy
Targeted Case Management may be provided based upon medical necessity.
The Physician Authorization may also be signed by Physician Assistant (PA) or an Advanced Practice Registered
Nurse (APRN). Authorization is valid for one calendar year:
I authorize the above identified services and/or evaluations as medically necessary and refer this student for
services/evaluation.
_________________
_____________________________________
Physician/ PA/ APRN Signature
Date of Referral
Return the signed form to:
Name ______________________________________________
County _____________________________________________
Address ____________________________________________
City/State/Zip _______________________________________
West Virginia Department of Education
March 2017
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