Washington Medicaid Reimbursement Program

Document Transmittal Form

School District

W

Number of Audiology Professional Logs
Number of Counseling Professional Logs
Number of Nursing Professional Logs
Number of OT Professional Logs
Number of PT Professional Logs
Number of Psychology Professional Logs
Number of SLP Professional Logs

Signature:
Date:

Please sign, date, and return this form to: Leader Services, P.O. Box O, Hazleton, PA 18201.

www.leaderservices.com ( Phone (800) 360-8511 ( Fax (570) 454-0162
Solutions for education
© 2004-2008 Leader Services [WA0108]

Document Transmittal Form

Leader Services

2008-01-29

Linda Snyder