Billing
Attention-New CPSE Mandatory Medicaid Forms_Changes in Requirements 9-1-2010
1. EI Monthly Summary Services Billing Form
2. Preschool/School Age Therapy rev 7-30-12
3. Preschool-Seit-ABA Only
4. Evaluations-EI Billing Form
5. Evaluations-CPSE-CSE Billing Form rev Apr 2016
6. Related Services CL-2R Form
7. Related Services CL-2R Form-Instructions
8. Medicaid Universal Evaluation-Services Script form_rev 12-2012
9. Chappaqua CSE Claim-Attendance Billing Form
10. Medicaid Eligibility Consent Form_english
11. Medicaid Eligibility Consent Form_spanish
12. Commonly used CPT codes rev Sept 2015
EI
1. EI Session Note rev 4-21-17
2. Daily EI Session Instructions
3. Westchester Co Session Note Policy and Procedure
4. Provider Progress Note_Mar 2014
5. OSC Parent Progress Report with Instructions
6. OSC Summary Report_Mar 2014
7. Authorization for Alternative Parental/Guardian/Caretaker Signature
8. Parental Consent For Annual Review Testing
9. Notification of Non-delivery of Authorized Services
10. Functional Outcomes Form rev May 2016
11. Speech Referral for Evaluation or Recommendation for Services Form
12. Parent Consent To Use E-mail to Exchange Personally Identifiable Info
CPSE
Billing
Parental Consents
Authorization For Alternative Signature Form
Email Consent
Service Forms
Prescription Referral For Evaluations
Notification Of Provision Mandated AAK CPSE
Verification Of Absence & Makeup Form
Notification Of Last Attend Date
Request For Change In Services
AAK SEIS Policy & Procedure Handbook Revised
CPSE Protocol Manual Westchester
CPSE Reporting Information & Due Dates
Westchester County CPSE Progress Reporting Form (2024)
Westchester County REQUEST/JUSTIFICATION FOR CHANGE IN SERVICE
Quarterly & Annual Progress Reporting Due Dates
Quarterly Progress Report Template
Annual Review Progress Report Instructions
Annual Review Progress Report Blank
Annual Review Progress Report Related Services
Annual Review Progress Report Related Services
ESY Regression Tool Instruction
ESY Regression Tool Template
Meeting Outcome Form CPSE & CSE
Evaluation Forms
Westchester Prescription Referral For Evaluations & Services
CSE
1. CSE Individual Treatment Log rev Sept 2015
2. CSE Group Treatment Log rev Sept 2015
3. Progress Report Due Dates rev 3-8-12
4. Progress Report
5. Educational Annual Review 2016
6. OT-PT Annual Review 2016
7. Speech & Language Annual Review 2016
8. Authorization for Alternative Parental/Guardian/Caretaker Signature
9. Extended School Year 2015
10.Meeting Recommendation Form-Annual Review
11. Meeting Recommendation Form-Excluding Annual Review
12. Suggested IEP Goal Form 2015
13. Parent Consent To Use E-mail to Exchange Personally Identifiable Info
Evaluations – EI
1. Consent for Evaluation
2. Consent to Obtain Physical
3. Consent to Release Information To Pediatrician
4. Consent to do Evaluation at School without Parent Present
5. Meeting Form
6. Parent Informing Form
7. Evaluation Checklist
8. Parental Waiver of Bilingual Evaluation Summary
9. Integrated Evaluation Summary pgs 1-3
10. Speech Referral for Evaluation or Recommendation for Services Form
Evaluations – CPSE
1. Consent for Evaluation
2. Consent to Obtain Physical
3. Consent to Release Information to Pediatrician
4. Classroom Observation Form
5. Child Outcome Summary
6. Parent Informing Form
7. Meeting Form
8. Consent to do Evaluation at School Without Parent Present
9. Parental Waiver of Bilingual Evaluation Summary
10. Preschool Prescription-Referral for Evaluations-Services Form_May 2015
11. Suggested IEP Goal Form 2015
Therapists Additional Forms
1. NPI-Memo
2. NYS Central Registry Form_Rev Apr 2011
3. Medical Form rev 9-16-11
4. Vaccination Refusal Form
5. IEP Direct Version 10 Goals