SBAP Manual Appendix B Forms - Leader Services · 2014. 4. 8. · Parental Consent Form in Spanish...
Transcript of 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
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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
PA School-Based ACCESS Program Provider ManualFORMS
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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
PA School-Based ACCESS Program Provider ManualFORMS
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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
U.S. Postal Service Address PO Box O Hazleton PA 18201
Package Delivery Address 75 Kiwanis Boulevard West Hazleton PA 18202
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.
PA School-Based ACCESS Program Provider ManualFORMS
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January 2005
Nursing Professional Services Log
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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
PA School-Based ACCESS Program Provider ManualFORMS
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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.
Updated: July 1, 2007
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.
Updated: July 1, 2007
PA School-Based ACCESS Program Provider ManualFORMS
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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:
Updated: July 1, 2007
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.
Updated: July 1, 2007
PA School-Based ACCESS Program Provider ManualFORMS
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Mon
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Speech, Language, and Hearing Log
Updated: December 2011
Appendix BFORMS
January 2005
B-16
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oup
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Grou
pInd
iv Gr
oup
Indiv
Grou
pInd
iv Gr
oup
Indiv
Grou
p Ind
iv Gr
oup
Indiv
Grou
pInd
iv Gr
oup
Indiv
Grou
pInd
iv Gr
oup
Indiv
Grou
p
Prog
ress
In
dica
tor
Teac
her C
onta
ct
Tim
e
Inst
ruct
iona
l A
ssis
tant
Con
tact
Ti
me
Pare
nt C
onta
ct
Tim
e
Equi
pmen
t Set
Up
Tim
e
Cha
rtin
g an
d R
epor
t W
ritin
g Ti
me
MD
T Pl
anni
ng
Tim
e
Trav
el
Tim
e
Oth
er
Tim
e
Tota
l
Trea
tmen
t Key
: SC
– Su
ppor
tive C
ouns
eling
CBT
– Co
mmun
ity-B
ased
Tra
ining
SS
T – S
ocial
Skil
ls Tr
aining
Mon
thly
Not
es m
ust f
ully
dis
clos
e th
e st
uden
t’s p
rogr
ess
or o
utco
me
for t
he m
onth
in re
latio
n to
the
treat
men
ts p
rovi
ded
and
the
med
ical
/men
tal h
ealth
-rel
ated
goa
ls in
the
IEP
—
—
—
Prog
ress
Indi
cato
r Key
: I
- Imp
rove
ment
SI -
Slig
ht Im
prov
emen
t
NC
- No C
hang
e R
- Re
gres
sion
Social Worker Log
Updated: December 2011
PA School-Based ACCESS Program Provider ManualFORMS
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.
Updated: December 2011
Appendix BFORMS
January 2005
B-18
w
ww
.lead
erse
rvic
es.c
om/p
a
sba
p@le
ader
serv
ices
.com
SB
AP
sup
port:
(8
00)
360-
8511
©
200
7 Le
ader
Ser
vice
s [P
A08
07]
Psyc
holo
gica
l Ser
vice
s Lo
g S
tude
nt’s
nam
e:
P
rovi
der’s
nam
e:
S
tude
nt’s
dat
e of
birt
h:
Se
rvic
e m
onth
/yea
r:
Pro
vide
r’s ti
tle:
S
choo
l:
Pro
vide
r’s s
igna
ture
:
Dat
e:
Dia
gnos
is/s
ympt
om(s
):
Serv
ice
Dat
e
Tim
e
Trea
tmen
t Tr
eatm
ent
Cod
e
Indiv
Grou
p Ind
iv Gr
oup
Indiv
Grou
pInd
iv Gr
oup
Indiv
Grou
pInd
iv Gr
oup
Indiv
Grou
p Ind
ivGr
oup
Indiv
Grou
p Ind
iv Gr
oup
Indiv
Grou
pInd
iv Gr
oup
Indiv
Grou
pInd
iv Gr
oup
Indiv
Grou
p Ty
pe o
f Se
rvic
e
Ref
er to
the
keys
be
low
for a
n ex
plan
atio
n of
the
Trea
tmen
t Cod
es
and
Prog
ress
In
dica
tors
Pr
ogre
ss
Indi
cato
r
Teac
her C
onta
ct
Tim
e
Inst
ruct
iona
l A
ssis
tant
Con
tact
Ti
me
Pare
nt C
onta
ct
Tim
e
Equi
pmen
t Set
Up
Tim
e
Cha
rtin
g an
d R
epor
t W
ritin
g Ti
me
MD
T Pl
anni
ng
Tim
e
Trav
el
Tim
e
Oth
er
Tim
e
Tota
l
Trea
tmen
t Key
: C
- Cou
nseli
ng C
I - C
risis
Inter
venti
on S
S - S
ocial
Skil
ls
—
—
—
—
Prog
ress
Indi
cato
r Key
: I
- Imp
rove
ment
SI -
Slig
ht Im
prov
emen
t
NC
- No C
hang
e R
- Re
gres
sion
Mon
thly
Not
es m
ust f
ully
dis
clos
e th
e st
uden
t’s p
rogr
ess
or o
utco
me
for t
he m
onth
in re
latio
n to
the
treat
men
ts p
rovi
ded
and
the
med
ical
/men
tal h
ealth
-rel
ated
goa
ls in
the
IEP
Psychological Services Daily Log
Updated: December 2011
PA School-Based ACCESS Program Provider ManualFORMS
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
U.S. Postal Service Address PO Box O Hazleton PA 18201
Package Delivery Address 75 Kiwanis Boulevard West Hazleton PA 18202
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
Updated: December 2011
PA School-Based ACCESS Program Provider ManualFORMS
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:
Updated: December 2011
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
Updated: December 2011
PA School-Based ACCESS Program Provider ManualFORMS
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.
Updated: December 2011
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.
Updated: December 2011