Child’s Name:	Month:	Year:

SS#	DOB:	MA#

School Name:	IEP IFSP

Service:

Service Provider’s Name:	Position:

Service Provider’s Number:	Certified	Provisional	Licensure

Service Provider’s Signature:

Date	Hours	Min	Service Description	Service Location	Session Type	Provider

Initials

Health-related service: Enter time – Hrs/Min: enter the time spent on the visit in hours and minutes. Round minutes to the nearest 15 minutes, depending on IEP requirements. Enter brief description of service provided.

Service Location: School (3) or Home (4)

Session Codes

Delivered Sessions:	I – Individual G – Group In – Indirect M – Make up Ma – Make up attempt / student absent

Absence Codes:	A – Student Absent B – School Closed (includes delayed opening or early closing) C – Student Unavailable D – Clinician / Therapist Absent E - Clinician / Therapist Unavailable (includes IEP meetings, testing) F – School Event (field trip, assembly, etc

This document is to be filed in the child’s Individual Record File or Early Intervention Folder

BOARD OF EDUCATION OF ALLEGANY COUNTY

Monthly Medicaid Related Services Record

Date Received _______________________________

MONTHLY MEDICAID SERVICES RECORD

ACPS Special Education

2007-10-02

Rick Metheny

Allegany County Public Schools