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Written Orders and Referrals must include:

The name of the child for whom the order is written;

The complete date the order was written and signed;

The service that is being ordered;

Provider’s contact information (office stamp or preprinted address and telephone number);

Signature of a NYS licensed and registered physician, a physician assistant, or a licensed nurse practitioner acting within his or her scope of practice (for psychological counseling services this also includes an appropriate school official and for speech therapy services, a speech-language pathologist*);

Medicaid State Plan Amendment (09-61) – Written Orders/Referrals

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