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Special Education

State Mandated Form for Documentation of Medicaid Service Delivery in Out-of-District Settings (28M/12) - Revised

To:Special Education Administrators, Private School Directors, Educational Collaborative Directors, Medicaid Contractors and other Interested Parties
From:Marcia Mittnacht, State Director of Special Education
Date:February 23, 2012

In 2010, the documentation form for Medicaid Service Delivery was developed for use by the out-of-district programs operated by approved private schools or educational collaboratives. The form (28M/12) has now been slightly revised and includes space for the out-of-district program to indicate the name of the program. This minor change allows schools who receive such forms from multiple programs to quickly identify the location the student was receiving services. The original memorandum in relation to this form is at:


Download PDF Document  Download MS WORD Document
This revised 28M/12 (dated February 2012) replaces any previous version.

Last Updated: February 23, 2012

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