From The Arc Autism Insurance Project in collaboration with Family Voices Indiana and About Special Kids Feel free to contact Family Voices Indiana at 317 944 8982 or info@fvindiana.org if you need additional resources or support. Sample Medical Order, Letter of Medical Necessity and Appeal Letter for ABA Services – Medicaid under EPSDT (ages 0-21) EPSDT – Early, Periodic Screening Diagnosis and T reatment MEDICAL TREATMENT ORDER SAMPLE FORMAT The prescribing physician should include: Physician’s order for ABA therapy Letter of medical necessity written by the physician or ABA provider, which includes: Patient history Diagnosis and prognosis Description of recommended services and explanation of why the services are medically necessary What the benefit to the patient will be, and Recommended length of time for the services Medical Necessity According to the Health and Human Services website: Medical Necessity under EPSDT In a rep
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