sbap manual appendix b forms - leader services · 2014. 4. 8. · parental consent form in spanish...

Appendix B FORMS

January 2005

Service Provider Update Form .................................................................................................. 2

Parental Consent Form .............................................................................................................. 3

Parental Consent Form in Spanish ............................................................................................ 4

Child Participation Form ........................................................................................................... 5

Medical Practitioner Authorization ........................................................................................... 6

Service Description Slip (blank) ............................................................................................... 7

Waiver for IEP Billing .............................................................................................................. 8

Nursing Professional Services Log ........................................................................................... 9

PCA Weekly Services Log ...................................................................................................... 10

PCA Weekly Services Log, continued .................................................................................... 11

PCA Weekly Services Log Instructions .................................................................................. 12

PCA Daily Services Log ......................................................................................................... 13

PCA Daily Services Log Instructions ..................................................................................... 14

Speech, Language, and Hearing Log ...................................................................................... 15

Social Worker Log .................................................................................................................. 16

Psychological Assessment Log ............................................................................................... 17

Psychological Services Daily Log .......................................................................................... 18

SBAP Transmittal Form .......................................................................................................... 19

Self-Audit Record Review Document .................................................................................... 20

Self-Audit Record Review Document, continued ................................................................... 21

Self-Audit Record Review Document Instructions................................................................. 22

Appendix BFORMS

January 2005

B-2

w w w. l e ad e rs e rv i c es . c o m/ p a s b a p @ l e a d e r s e r v i c e s . c o m S BA P s u pp o r t : ( 8 00 ) 36 0 - 85 11

Solutions for special education © 2011 Leader Services. All rights reserved [PA0611]

Pennsylvania Service Provider Update Form DIRECTIONS: Use this form to update your list of service providers currently participating in the School-Based ACCESS Program (SBAP). You must notify Leader Services when service providers are added to or leave your staff.

Provide only the information that has changed and indicate “A” for add, “D” for delete, or “U” for update in the Status column. To (U) update service provider information, enter the new information, followed by the old information in parentheses. Example: to request a service provider name change, enter the new name followed by the old name: Smith, Jane A. (Miller, Jane A.). Be sure to indicate the total number of pages submitted. Please retain a copy of the form for your files.

Page of

EDUCATION AGENCY INFORMATION Education Agency Name Telephone

Signature Title Date Completed

SERVICE PROVIDER INFORMATION

Service Provider Name Service Specialty Social Security

Number License and/or

Certification Number Status

(A, D, or U)

Service Provider Update Form

PA School-Based ACCESS Program Provider ManualFORMS

B-3

January 2005

Parental Consent FormUse this form to notify parents/guardians of your intent to bill Medical Assistance on behalf of their child.

PA Medical Assistance (MA) Billing Parental Consent Form

Local Education Agencies (LEAs) are eligible to receive federal Medicaid reimbursement for medically necessary services provided to their special education students when the services meet the requirements of the state’s Medicaid program and are provided in accordance with the students’ IEP. The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) and the Family Educational Rights and Privacy Act (FERPA) require schools to obtain written parental consent to share students’ education and health-related records such as IEPs and Evaluation Reports. We are requesting your permission to share this information with the PA Department of Education, the PA Department of Public Welfare, and a physician or nurse practitioner in order to bill Medical Assistance. In addition to the Medicaid-covered services your child receives as part of his/her IEP, MA will continue to pay for medically necessary, Medicaid-covered services that are provided to your child outside of school. ________________________________________________________________________ I understand that… if I give permission, I may withdraw it for future services at any time. However, it does not

negate an action that has occurred after consent was given and before the consent was revoked.

my refusal to give consent will not change the services my child receives under his/her

IEP. whether I consent or refuse, I will not have to pay for these services. upon request, I may receive copies of my child’s records that are disclosed as a result of

this authorization.

I give my child’s school permission to share my child’s education and health-related information and bill Medical Assistance.

I do not give my child’s school permission to share my child’s educational and

health-related information and bill Medical Assistance. Name of School

Student’s Full Name Date of Birth

IEP Meeting Date Anticipated Duration of Services

Parent/Guardian Name (print) Parent/Guardian Signature Date

Updated: Oct. 12, 2006

Appendix BFORMS

January 2005

B-4

Parental Consent Form in Spanish

Formulario de Consentimiento de los Padres para Facturar a Asistencia Médica (MA, en inglés) de Pennsylvania

Las Agencias Educativas Locales (LEA, por sus siglas en inglés) son elegibles para recibir reembolsos del programa federal de Medicaid para servicios que son médicamente necesarios y provistos a los estudiantes de educación especial, siempre y cuando estos servicios cumplan con los requisitos del programa estatal de Medicaid y sean provistos de acuerdo con el IEP (Plan Educativo Individualizado) del alumno. El Acta para el Mejoramiento de la Educación de Individuos con Impedimentos del 2004 (IDEA, por sus siglas en inglés) y el Acta para los Derechos Educativos y la Privacidad de Familias (FERPA) requieren que las escuelas obtengan un consentimiento de los padres para compartir los historiales educativos y médicos de los estudiantes, tales como sus IEP y los Reportes de Evaluación. Estamos pidiendo su permiso para compartir esta información con el Departamento de Educación de PA, el Departamento de Bienestar Público, y un doctor o enfermera profesional para así poder facturar a Asistencia Médica. Además de los servicios cubiertos por Medicaid que su niño recibe como parte de su IEP, Asistencia Médica continuará pagando los servicios que su niño recibe fuera de la escuela si éstos son médicamente necesarios y cubiertos por Medicaid. ________________________________________________________________________ Entiendo que…

si doy mi permiso, puedo cancelarlo en cualquier momento para servicios en el futuro. Sin embargo, esa cancelación no anula ninguna acción que haya ocurrido después del consentimiento y antes de su cancelación.

• mi rechazo a dar consentimiento no cambiará los servicios que mi niño recibe en su IEP. • con o sin mi consentimiento, no tendré que pagar por estos servicios. • a petición mía, puedo recibir copias de todos los historiales de mi niño que serán

compartidos como consecuencia de esta autorización.

Yo doy permiso a la escuela de mi niño a que comparta información acerca de la educación y salud de mi niño, y que facture a Asistencia Médica

Yo no doy permiso a la escuela de mi niño a que comparta información acerca de la

educación y salud de mi niño, ni que facture a Asistencia Médica.

Nombre de la escuela

Nombre completo del estudiante Fecha de nacimiento

Fecha de la reunión del IEP Duración anticipada de servicios

Nombre del padre/ guardián (en letra de imprenta)

Firma del padre/ guardián Fecha

Updated: Oct. 12, 2006


B-5

January 2005

U.S. Postal Service Address PO Box O Hazleton PA 18201

Package Delivery Address 75 Kiwanis Boulevard West Hazleton PA 18202

Phone: (800) 360-8511 Fax: (570) 455-4526 Web site: www.leaderservices.com DRSPA0013E0030704LS

Pennsylvania Child Participation Form Complete this form to enter new eligible SBAP students. Leader will add this information to its claims processing database and use the information to preprint your LEA’s Service Description Slips. Use the blank area at the bottom of the Service Provider Information section to enter a service specialty that is not listed. Please mail or fax completed forms to Leader Services at the PO Box address or fax number listed below.

STUDENT INFORMATION EDUCATION AGENCY NAME LEA STUDENT TRACKING NUMBER - Optional DATE

STUDENT NAME

Last First MI STUDENT’S BIRTH DATE (mm-dd-yy)

STUDENT’S SOCIAL SECURITY NUMBER GENDER ACCOUNTING UNIT NUMBER (AUN) - Optional

M F MEDICAL ASSISTANCE (MA) ID NUMBER - 10 DIGITS

SERVICE PROVIDER INFORMATION

SERVICE SPECIALTY SERVICE PROVIDER NAME SCHOOL BUILDING (optional)

SPEECH, LANGUAGE AND HEARING SERVICES

1)

2)

PHYSICAL THERAPY

1) 2)

OCCUPATIONAL THERAPY

1) 2)

NURSING SERVICES – REGISTERED

1) 2)

NURSING SERVICES – LICENSED PRACTICAL

1) 2)

PERSONAL CARE ASSISTANT SERVICES

1) 2)

ONGOING PSYCHOLOGICAL SERVICES

1) 2)

TEACHER HEARING IMPAIRED

1) 2)

ONGOING SOCIAL WORK SERVICES

1) 2)

1) 2)

Child Participation Form

Appendix BFORMS

January 2005

B-6

Medical Practitioner Authorization

www.leaderservices.com/pa [email protected] SBAP support: (800) 360-8511© 2007-11 Leader Services [PA0211]

Medical Practitioner Authorization for SBAP Services

Student’s name:

I reviewed the Individualized Education Program (IEP) for this student and agree that the following evaluations and health-related services recommended by the IEP team are both appropriate and medically necessary.

Date of the current IEP meeting: Month / day / year

Evaluations included in this IEP

Audiology Occupational Therapy Orientation and MobilityPhysical Therapy Psychiatric PsychologicalSocial Work Speech/Language

Related Services FrequencyProjectedStart Date

AnticipatedDuration

Audiology Nursing Occupational Therapy Orientation and Mobility Personal Care Assistant Physical Therapy Psychiatric Psychological Social Work Special Transportation Speech/Language Hearing Impaired

Authorized Signature: Authorized Date:

Practitioner Title: Record Review Time:No. of minutes

A School or Licensed Psychologist can recommend and authorize psychological services only

A Licensed Social Worker, Licensed Professional Counselor, or Licensed Family Counselor can recommend and authorize social work services only.

Authorized Date is the Authorized Billing Date for all services listed above.

DIRECTIONS: This form must be completed and signed by an MD, DO, or CRNP before most medical/mental health-related services may be provided and billed to MA. A prescription is accept-able in lieu of this form. The medical/mental-health authorizing document should be maintained in the student’s record with other SBAP documentation.

Updated: Feb. 1, 2010


B-7

January 2005

Service Description Slip (blank)DIRECTIONS: Complete this form using the information entered on the specialty log (e.g. Nursing Log, Psychological Assessment, etc.), and submit the form to Leader. Note: As a convenient alterna-tive to using the paper form, both the Service Logs and Service Description Slips can be completed online. Visit: www.leaderservices.com for information.

Pennsylvania Service Description Slip Education Agency Name

Service Month/Year

Student Name (Last, First, MI)

Date of Birth

Service Provider

School Building

Service Specialties 1. Individual Services 2. Group Services Please check (x) the appropriate service specialty Please enter the total number of hours and minutes per day

01 Audiology Day Hours Minutes Day Hours Minutes 02 Nursing (RN) 1 1 03 Occupational Therapy 2 2 04 Personal Care Assistant 3 3 05 Physical Therapy 4 4 06 Physician 5 5 07 Psychiatric 6 6 08 Psychology 7 7 09 Social Work 8 8 10 Speech/Language/Hearing 9 9 11 Vision 10 10 12 Orientation & Mobility 11 11 13 Teacher of the Hearing Impaired 12 12 14 IEP 13 13 15 Nursing (LPN) 14 14

15 15

Signatures 16 16 17 17 18 18 Service Provider’s Signature 19 19 Date / / 20 20 21 21 22 22 Supervisor’s Signature 23 23 (required when services are provided by paraprofessionals) 24 24 Date / / 25 25 26 26 27 27 28 28 29 29

30 30

(800) 360-8511



31 31 WHITE COPY – BILLING OFFICE YELLOW COPY – SBAP COORDINATOR PINK COPY – SERVICE PROVIDER

Appendix BFORMS

January 2005

B-8

(800) 360-8511 www.leaderservices.com PA0711

Waiver for IEP Billing

Student Name: Date of Birth: The

(School District, Charter School or MAWA) has engaged the

(Intermediate Unit or Approved Private School) to develop and monitor the Individualized Education Plan for the above named student. We are aware that the

(Intermediate Unit or Approved Private School) will be using their staff to perform the IEP functions. Because of this we will waive the SBAP billing for the IEP development and review to the (Intermediate Unit or Approved Private School) Special Education Director: Signature: Date:

Waiver for IEP BillingDIRECTIONS: This form is used to authorize a waiver permitting an IU or APS to bill for IEP meet-ings held for a student of your LEA. Once a waiver is authorized, it can only be revoked by official written correspondence from the LEA to the IU or APS. A copy of all correspondence concerning waivers should be retained in the student’s file with other SBAP required documentation.


B-9

January 2005

Nursing Professional Services Log

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P

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der’s

nam

e:

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tude

nt’s

dat

e of

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onth

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Pro

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S

choo

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Pro

vide

r’s s

igna

ture

:

Dat

e:

D

iagn

osis

/sym

ptom

(s):

M

edic

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onth

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Updated: December 2011

Appendix BFORMS

January 2005

B-10

PCA Weekly Services Log

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© 2006-08 Leader Services [PA0908]

Personal Care Assistant Services Weekly Log

Sheet of

Student Information (please print) PCA Information (please print)

Name: PCA Name: Date of Birth: PCA Name:

Diagnosis: Supervisor’s Name:(required)

Date: Daily Notes

PCA Signature: Total Daily Time: Enter additional daily notes below if needed.

Date: Daily Notes

PCA Signature: Total Daily Time: Enter additional daily notes on the next page if needed.

Updated: July 1, 2007


B-11

January 2005

PCA Weekly Services Log, continued

Supervisor’s Signature: (required) Date:

Student’s Name: Sheet of

Date: Daily Notes

PCA Signature: Total Daily Time: Enter additional daily notes below if needed.

Date: Daily Notes PCA Signature: Total Daily Time:Enter additional daily notes below if needed.

Date: Daily Notes PCA Signature: Total Daily Time: Enter additional daily notes on a separate page if needed.


Appendix BFORMS

January 2005

B-12

PCA Weekly Services Log Instructions

Personal Care Assistant Services Weekly Log Instructions

Sheet ___ of ____

Please number every sheet as well as the total number of sheets. For example: Sheet 1 of 2 and Sheet 2 of 2.

Student Information Section Student Name Print the student’s full name on every sheet. Date of Birth Print the student’s date of birth.

Diagnosis Print the student’s medical or mental-health diagnosis.

PCA Information Section PCA Name Print the PCA’s full name. If more than one provider assists the same student, the

providers may share a log but each provider must enter separate notes in the Daily Notes Section.

Supervisor Name (required)

Print the name of the supervisor who is authorized to oversee the PCA and can attest that the services were provided one-on-one to the student.

Daily Notes Section

Date Enter the month, day and year on which the PCA service was provided.

Blank lines in Daily Notes Section

The daily note must summarize the student’s activities as they relate to the activities indicated in the student’s schedule. However, any change in time or activity not indicated in the student’s schedule should be described in detail.

For example, if a PCA typically assists a student from 2:30 p.m. to 3 p.m. weekdays, but the time performing the activity is shortened on a particular weekday from 2:30 p.m. to 2:45 p.m. due to a change in the school’s schedule (such as a field trip or inclement weather), this activity and time change must be explained in detail. If additional space is needed to record a detailed daily summary, continue entering text in the next block. Notes: Educational activities, such as helping a student complete a math problem, are

not claimable. Do not enter educational activities on the log.

Claimable services must be provided one-to-one with a student. If the PCA monitors or assists more than one student at the same time, the service time is not claimable.

PCA Signature The PCA must sign on this line after entering the daily notes. Total Daily Time

Enter the total daily time spent with the student, including indirect time (if applicable) that relates to the services that were provided to the student. Examples of indirect services time:

• arranging a student’s classroom, desk, and assignments to accommodate the student’s needs prior to the student’s arrival in class

• working with a nurse, speech therapist, or other therapist to coordinate a student’s treatment plan

Supervisor’s Signature (required) The supervisor must sign the log weekly.

Date The supervisor must date the log weekly.



B-13

January 2005

PCA Daily Services Log

03-07 - © 2007 Leader Services. All rights reserved.

Sheet: of: Personal Care Assistant Daily Encounter Log

Student Information LEA Name: Date:

Student Name: DOB: Diagnosis:

Provider Information PCA: Signature:

PCA: Signature:

PCA: Signature:

PCA: Signature:

Time In Time Out Minutes Description of activity, location, and outcome PCA Initials

Total Minutes:

Supervisor Name: Signature: Date:


Appendix BFORMS

January 2005

B-14

PCA Daily Services Log Instructions

Personal Care Assistant Daily Encounter Log Instructions

Sheet ___ of ____ If using multiple sheets, please number every sheet as well as the total number of sheets. For example: Sheet 1 of 2 and Sheet 2 of 2.

Student Information SectionLEA Name School District, Intermediate Unit, Approved Private School, or Charter School.

Date Enter the month, day and year on which the PCA service was provided.

Student Name Print the student’s full name on every sheet. Date of Birth Print the student’s date of birth.

Diagnosis Print the student’s medical or mental-health diagnosis.

PCA Information SectionPCA Name Print the PCA’s full name. If multiple PCAs assist the same student, every PCA’s full

name must be listed.

PCA Signature Each PCA must sign on their corresponding signature line in the Provider Information Section at the end of each day

Description of Activity, Location, and Outcome SectionTime In Enter the actual time the service activity begins.

Time Out Enter the actual time the service activity ends.

Minutes Calculate the duration of the service time. Time Out minus Time In.

Description ofActivity

Describe the service activity in detail, where the activity was provided to the student due to the student’s medical/mental health condition/diagnosis, and the outcome.

Example: Monitored John’s medical condition during gym class by observing him for signs of seizure activity. John participated in the volleyball game with his peers; no seizure activity was observed. Note: In the event John has a seizure or displays signs of seizure activity, describe in detail the event, interventions, care provided, and outcome.

Service activities not to be documented in the log: Educational activities, such as helping a student complete a math problem Services not detailed in the IEP Group services, such as monitoring or assisting more than one student at the

same time

PCA Initials Each service activity must be initialed by the attending PCA.

Supervisor Name Print the name of the supervisor who is authorized to oversee the PCA. The supervisor should be able to attest that the services claimed to MA were provided to the student on the encounter date, and the service was provided one-on-one with the student as detailed in the IEP.

Signature The supervisor must sign and date the daily log.



B-15

January 2005

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the

IEP

Speech, Language, and Hearing Log


Appendix BFORMS

January 2005

B-16

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Soci

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nam

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Se

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Social Worker Log



B-17

January 2005

Psychological Assessment Log

www.leaderservices.com/pa [email protected] SBAP support: (800) 360-8511 ©2011 Leader Services [PA0511]

Psychological Assessment Log

LEA Name: Psychologist’s Name:

Student’s Name: Date of Birth:

Diagnosis/Symptom(s):

Initial Evaluation Re-evaluation

Evaluation Activity Date Time Date Time Timehrs. min.

MDT Meeting

Reviewing Records

Preparing and Sending Materials to Parents

Preparing and Sending Correspondence to Other Professionals

Administering and Scoring Psychological Tests

Completing Classroom Observation

Consulting with Teacher

MDT Staffing/Determining Eligibility Recommendations to IEP Committee (excluding IEP meeting)

Preparing MDT Assessment Summary

Meeting with Parents (excluding IEP meeting)

Travel

Other (Explain)

IEP Date (Billing Date)

Total Time

Notes (optional):

Psychologist’s Signature: Date:

Note: Only psychological assessments that lead to and result in the creation of an IEP or the continuation of an IEP can be billed to Medical Assistance.


Appendix BFORMS

January 2005

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Psychological Services Daily Log



B-19

January 2005

SBAP Transmittal FormDIRECTIONS: This form should be used as a cover document when forms are sent to Lead-er via mail or fax. Enter the type and quantity of form(s) sent. Leader uses this Transmittal Form to verify receipt of all forms noted on it. When there is a discrepancy, Leader contacts the person designated on the Transmittal Form.

SL99 – LEADER SCHOOL

SBAP TRANSMITTAL FORM

No. of Documents

Type of Document

Phone Number: E-mail Address: Signature: Date:

Phone: (800) 360-8511 Fax: (570) 455-4526 Web site:www.leaderservices.com



Appendix BFORMS

January 2005

B-20

Self-Audit Record Review DocumentDIRECTIONS: This form allows an LEA to conduct a self-audit to evaluate the complete-ness and quality of its SBAP documentation. Completing periodic record review self-assess-ments can help ensure preparedness for state and Leader SBAP audits.

Rev. 2/11 [1] DRSPA0066E0020309LS

PA SBAP SELF-AUDIT RECORD REVIEW DOCUMENT

Student Name: DOB:

Service: Service Date:

LEA Reviewer: Date of Review:

1. Parental Consent Form:

School identified: Yes No

Student-specific: Yes No

IEP Meeting date identified: Yes No

Duration of services identified: Yes No

Permission for billed service: Yes No

Authorizing signature and date: Yes No

2. IEP:

IEP: Yes No

Billed service listed: Yes No

Frequency: Yes No

Duration of service: Yes No

3. Medical Authorization:

Authorization for billed service: Yes No

Date of service covered by authorization: Yes No

Frequency/duration matches IEP: Yes No

4. Service Provider Log:

Student specific (name and date of birth): Yes No



B-21

January 2005

Self-Audit Record Review Document, continued

Rev. 2/11 [2] DRSPA0066E0020309LS

4. Service Provider Log (cont):

Diagnosis or description of symptom: Yes No

Date of service: Yes No

Type of service: Yes No

Length of service: Yes No

Collateral services, if billed: Yes No

Treatment code indicator: Yes No

Daily progress indicator: Yes No

Monthly progress statement: Yes No

Service provider signature and title: Yes No

Supervisor signature, if needed: Yes No

Legibility of log: Yes No

5. Attendance Records:

Student in attendance on date service billed: Yes No

Service Provider in attendance on date service billed: Yes No

6. Service Provider List:

License/Certification number: Yes No

License/Certification current: Yes No

7. Corrective Action Needed:

8. Additional Comments:


Appendix BFORMS

January 2005

B-22

Rev. 2/11 [1] DRSPA0066E0020309LS

PA SBAP SELF-AUDIT RECORD REVIEW INSTRUCTIONS

To conduct an LEA self-audit, the reviewer selects a particular billing month and date of service. If possible, the review should entail a variety of types of service billed to MA. Documentation related to the selected MA billed students is gathered in preparation of the self-audit. Needed for the review are:

Student IEPs Service Description Slips, if used Service Provider Logs Parental Consent Forms Medical Practitioner Authorization Forms LEA List of SBAP Service Providers Service Provider Licensure/Certification Documents Student Attendance Records Service Provider Attendance Records

An individual Self-Audit Record Review Document should be used for each student and type of service and date of service included in the review. Instructions for completion of the form follow:

Student Name: Enter the student’s name.

DOB: Enter the student’s date of birth.

Service: Enter the type of service being reviewed.

Service Date: Enter the date of service being reviewed.

LEA Reviewer: Enter the name of the LEA reviewer.

Date of Review: Enter the date of the LEA review.

1. Parental Consent Form:

School identified: If the Local Education Agency (LEA) is identified, circle Yes. If not, circle No.

Student-specific: If the Parental Consent Form is student- Identifiable including student’s name and date of birth, circle yes. If not, circle no.

IEP meeting date identified: If the IEP meeting date is identified, circle Yes. If not, circle No.

Duration of services identified: If the duration of services is identified, circle Yes. If not, circle No.

Permission for billed service: If the parent/guardian of the student granted permission by checking the appropriate check box, circle Yes. If permission was denied, circle no. If no box was checked, circle No.

Authorizing signature If the parent/guardian of the student signed and dated the form, circle Yes. If not, circle No.

Self-Audit Record Review Document Instructions



B-23

January 2005

Rev. 2/11 [2] DRSPA0066E0020309LS

2. IEP:

IEP: If an IEP exists for the student, circle yes. If not, circle no.

Billed service listed: If the service under review is listed in the IEP, circle yes. If not, circle no.

Frequency: If the frequency of the reviewed service is listed in the IEP, circle yes. If not, circle no.

Duration: If the duration of the reviewed service is listed in the IEP, circle yes. If not, circle no.

3. Medical Authorization:

Authorization for billed service: If medical authorization exists for the service under review, circle yes. If not, circle no.

Date of service covered by If the date of the reviewed service is covered authorization: by the authorization, circle yes. If not, circle no.

Frequency/Duration matches IEP If the frequency/duration on the Medical Authorization matches the frequency/duration in the IEP, circle Yes. If not, circle No.

4. Service Provider Log:

Student specific: If the service provider’s log is student identifiable, circle yes. If not, circle no.

Diagnosis or description If a diagnosis or a description of why the provider is of symptom: seeing the student is recorded on the service provider’s log, circle Yes. If not, circle No.

Date of service: If the reviewed date of service is recorded on the service provider’s log, circle yes. If not, circle no.

Type of service: If the reviewed type of service is recorded on the service provider’s log, circle yes. If not, circle no.

Length of service: If the length of the reviewed service is recorded on the service provider’s log, circle yes. If not, circle no.


Appendix BFORMS

January 2005

B-24

Rev. 2/11 [3] DRSPA0066E0020309LS

Collateral services, if billed: If collateral services for the reviewed service date are listed on the service provider’s log, circle yes. If not, circle no.

Daily progress indicator: If one of the four progress indicators was recorded for the reviewed service date, circle yes. If not, circle no.

Monthly progress statement: If a detailed monthly progress statement and/or detailed notes are recorded on or attached to the service provider’s log, circle yes. If not, circle no.

Service provider signature and If the service provider’s signature and title appear title: on the service log, circle yes. If not, circle no.

Supervisor signature, if needed: If a supervisor signature is required and appears on the service log, circle yes. If required and missing, circle no.

Legibility of log: If the service provider’s log is legible, circle yes. If not, circle no.

5. Attendance Records:

Student in attendance If the student was in school on the reviewed on date service billed: service date, circle yes. If not, circle no.

Service Provider in attendance If the service provider was present on the date of on date service billed: the reviewed service, circle yes. If not, circle no.

6. Practitioner List:

License/Certification number: If a license/certification number for the service provider rendering the reviewed service is present on the LEA’s service provider list, circle yes. If not, circle no.

License/Certification current: If the service provider’s license/certification is current, circle yes. If not, circle no.

7. Corrective Action Needed: Enter any corrective action needed to meet record keeping requirements.

8. Additional Comments: Enter any additional comments concerning the review.
