PSSHSP Prescription Templates for Services
Medicaid-Compliant Prescription Templates for SERVICES:
Template Options (fillable Pdf options - Word options below)
Fillable Drop-down menu Template (type-in AND drop-down menu options). This option is a fillable pdf that also contains drop-down menus with pre-selected items to choose from. This is a recommended template: Click Here.
Fillable Template (type-in only option). This option is a fillable pdf. It will allow you to type in information in the designated fields: Click Here.
Blank Template. This should be used if you want to print the form and write in the information: Click Here.
Important Note: All previous Templates using the "As per IEP" narrative have been removed from the Knowledge Base. Please discontinue using any "Per IEP" templates.
- All Full-Service Medicaid counties are requiring that all prescriptions show the specific frequency, duration, class designation (I/G), AND delivery (weekly, monthly, total).
SAMPLE PRESCRIPTION
Unsure how to pre-fill a prescription template? Please review our sample pre-filled script below. Items in red can be pre-filled before the prescription goes to the practitioner. Items in purple must be completed by the practitioner.
Template Options (WordDoc)
Fillable Drop-down menu Template (type-in AND drop-down menu options). This option is an editable form that contains hidden drop-down menus with pre-selected items to choose from. This is a recommended template: Click Here.
Blank Template. This should be used if you want to print the form and write in the information: Click Here.
HOW TO USE HIDDEN DROP DOWN MENUS
Hover over the upper left-hand corners of the boxes containing the menus (service, To, From, and Weekly/Monthly). When you hover your mouse over the corner, you will see a small gray box appear; click on this box to see the menu. Select your item from the menu.