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West Virginia School-Based Medicaid Services Forms

Word document versions of billing forms are only to be used to enter and save student demographics at the top of the billing forms.

The form content MUST NOT be altered.

* School Audiology Billing Form (PDF) (Word)

* School Occupational Therapy Billing Form (PDF) (Word)

* Personal Care Log Sheet (PDF) Updated Form November 2015

* School Physical Therapy Billing Form (PDF) (Word)

* Physician Authorization Form 2015 (Word) Updated October 2015

* School Nursing Billing Form (PDF) (Word)

* School Psychological Billing Form (PDF) (Word)

* Specialized Transportation (PDF) (Word) Updated August 2016

* Targeted Case Management Billing Form (Word) Updated August 2016

* School Speech Therapy Billing Form (PDF) (Word)

* Service Care Plan (Word)


* Medicaid Consent/Release of Information August 2015 (PDF) (Word)

* Notice to Parents (send annually) August 2015 (PDF)

* Letter from DHHR (PDF)


Contact Information:

Terry Riley
West Virginia Department of Education
Phone: 304-957-9833 ext. 53223