Provider Forms

These forms should be used to obtain all of the information required to maintain compliance with the Michigan Medicaid School Based Services Program. If you have any questions regarding a form, please contact the Medicaid Assistant.

Physician Authorization Form

The Physician Authroization Form should be filled out by the provider and turned in to the Medicaid Assistant. It is important to fill this out in a timely manner so that we can obtain a physician signature and begin billing for services rendered.

PDF DocumentPhysician Authorization Form

Personal Care Authorization Form

A Personal Care Authorization form must be completed and placed in the student's file if they have Personal Care services listed in their IEP.

PDF DocumentPersonal Care Authorization Form

Personal Care Log

A completed, signed and dated Personal Care Log must be completed for each student for whom personal care services will be reported. Each para-professional will record the services they render to each student on their log on a daily basis. At the end of the month, the para-professional will enter their servcies into TIENET, and then turn in their signed and dated logs to the designated person/location in the district.

PDF DocumentPersonal Care Log

Medicaid Electronic Signature Form

Since services are recorded electronically, an Electronic Signature Form is needed for all providers. This form is intended to record a physical copy of the provider’s signature in the event of an audit. The electronic signature is a unique combination of the provider’s login account name, password, and signature. This unique combination will ensure, for audit and confidentiality purposes, that all work completed electronically is completed by the provider.

PDF DocumentProvider Electronic Signature Verification

Documentation of Supervision Form

Certain specified services may be provided under the direction of or under the supervision of another clinician. For the supervising clinician, "under the direction of" means that the clinician is supervising the individual's care which, at a minimum, includes seeing the individual initially, prescribing the type of care to be provided, reviewing the need for continued services throughout treatment, assuring professional responsibility for services provided, and ensuring that all services are medically necessary. "Under the direction of" requires face-to-face contact by the clinician at least at the beginning of treatment and periodically thereafter.

PDF DocumentDocumentation of Supervision OT

PDF DocumentDocumentation of Supervision PT

PDF DocumentDocumentation of Supervision SLP

PDF DocumentDocumentation of Supervision SW