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Expanded Coordinator Sessions

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PARTICIPANTS
  • ☑Child
  • ☑Parent/caregiver
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By entering my pin number, I/We certify that on the dates selected, the selected children received the services noted and that documentation exists and is maintained on file verifying the delivery of said services in accordance with all relevant Federal, State and Local Laws and Regulations governing the Medicaid process.

NOTE: Credentials are REQUIRED to sign. Please verify credentials below. If they are not correct, update them on your profile page.

Name & Credentials:

NPI:

DATE: today

I Agree
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By entering my pin number. I/We certify that on the dates selected the selected services which I previously verified and signed were not accurate and must be changed in order to accurately reflect the services that took place for the specified child on the specified date.

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Script signing.

This is the first session in a new enrollment.
Please sign and date a prescription.
Date should match first date of service in the new enrollment.

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EI-PORTAL - SERVICES

Therapist Billing

EI-PORTAL - SERVICES

Erie County

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Coordinator
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By entering my pin number, I/We certify that on the dates selected, the selected children received the services noted and that documentation exists and is maintained on file verifying the delivery of said services in accordance with all relevant Federal, State and Local Laws and Regulations governing the Medicaid process.

NOTE: Credentials are REQUIRED to sign. Please verify credentials below. If they are not correct, update them on your profile page.

Name & Credentials:

NPI:

DATE: today

I Agree
X

By entering my pin number. I/We certify that on the dates selected the selected services which I previously verified and signed were not accurate and must be changed in order to accurately reflect the services that took place for the specified child on the specified date.

I Agree
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Coordinator Sessions

Please Note: default listing only includes the past 60 days sessions.

Export for Billing:A | B | C

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PreKEval
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By entering my pin number, I/We certify that on the dates selected, the selected children received the services noted and that documentation exists and is maintained on file verifying the delivery of said services in accordance with all relevant Federal, State and Local Laws and Regulations governing the Medicaid process.

NOTE: Credentials are REQUIRED to sign. Please verify credentials below. If they are not correct, update them on your profile page.

Name & Credentials:

NPI:

DATE: today

I Agree
X

By entering my pin number. I/We certify that on the dates selected the selected services which I previously verified and signed were not accurate and must be changed in order to accurately reflect the services that took place for the specified child on the specified date.

I Agree
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