____________________ COUNTY SCHOOLS
(Return the signed form to the county school address listed below)
ATTN:
Address____________________________
City_______________________, WV ______ Zip
__
PHYSICIAN AUTHORIZATION FORM
TO:
_________________________________________
Physician’s Name (Please Print)
FOR:
__________________________________
Student’s Name
_____________
Date of Birth
_________________________________________
Address
____________________________________
School
________
Grade
City/State
____________________________________
Medicaid number
The following services have been included on the above-named student’s Individual Education Program and/or
Service Care Plan.
Service
√ = service
included on
Individual
Education
Program and/or
Service Care Plan
Frequency/
Duration
√ = Evaluation
Re-Evaluation
Diagnosis Codes - ICD – 10 Code(s) that justify
therapy being provided:
Physical
Therapy
Occupational
Therapy
Speech
Therapy
Audiology
Physician Authorization can 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
WVDE
____________________
Date of referral
October 1, 2015