Forms

This site includes forms designed by the Pennsylvania Department of Education to ensure that students with disabilities receive a free, appropriate, public education. Forms are available for the Infant-Toddler/Early Intervention, Preschool/Early Intervention, and School-age programs, and include both annotated and non-annotated versions. Forms are available as Word and pdf documents.

Results 71-79 of 79
Pennsylvania Medical Assistance Billing Parental Consent cover image

Pennsylvania Medical Assistance Billing Parental Consent

Effective Date:1/1/0001 12:00:00 AM
This form allows parents to choose whether to give consent for the Local Educational Agency (LEA) to access reimbursement from Medical Assistance for special education services.
Age:Preschool,Infant/Toddler
Language:English
Pennsylvania Medical Assistance Billing Parental Notice  cover image

Pennsylvania Medical Assistance Billing Parental Notice

Effective Date:1/1/0001 12:00:00 AM
The PA Medical Assistance Billing Parental Notice is effective beginning October 2016. This notice informs parents of their rights regarding consent for accessing benefits and insurance to pay for services under the Individuals with Disabilities Education Act (IDEA).
Age:Infant/Toddler,Preschool
Language:English
Pennsylvania Medical Assistance Billing Parental Consent cover image

Pennsylvania Medical Assistance Billing Parental Consent

Effective Date:3/17/2013 11:00:00 PM
The PA Medical Assistance Billing Parental Consent is effective beginning October 2016. This form allows parents to choose whether to give consent for the Local Educational Agency (LEA) to access reimbursement from Medical Assistance for special education services.
Age:School Age
Language:English
Pennsylvania Medical Assistance Billing Parental Notice cover image

Pennsylvania Medical Assistance Billing Parental Notice

Effective Date:3/17/2013 11:00:00 PM
The PA Medical Assistance Billing Parental Notice. The LEAs can apply for reimbursement for services, a one-time written parental consent is required by The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) under Part 300 (Assistance to the States for the Education of Children with Disabilities) and the Family Educational Rights and Privacy Act (FERPA). By signing the parental consent document, you are authorizing the LEA to share your child’s information such as records or information about the services that may be provided to your child with the PA Department of Education, the PA Department of Public Welfare, and a physician or nurse practitioner in order to bill Medical Assistance for services your child receives as part of his/her IEP. The only purpose of this disclosure is to bill for services provided.
Age:School Age
Language:English
Pennsylvania Medical Assistance Billing Parental Notice - Annotated cover image

Pennsylvania Medical Assistance Billing Parental Notice - Annotated

Effective Date:11/1/2017 12:00:00 AM
This is an annotated version of the Medical Assistance Billing Parental Notice form which provides notice to parents on giving consent for the Local Educational Agency (LEA) to access reimbursement from Medical Assistance for special education services. This annotation offers guidance to Early Intervention staff. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.
Age:Infant/Toddler,Preschool
Language:English
Pennsylvania Medical Assistance Billing Parental Consent - Annotated cover image

Pennsylvania Medical Assistance Billing Parental Consent - Annotated

Effective Date:10/1/2016 12:00:00 AM
This is an annotated version of the Medical Assistance Billing Parental Consent form. This annotation provides guidance for understanding the options outlined in this form.
Age:Infant/Toddler,Preschool
Language:English
Communication Plan for a Child Who Is Deaf or Hard of Hearing (Annotated) - School Age cover image

Communication Plan for a Child Who Is Deaf or Hard of Hearing (Annotated) - School Age

Effective Date:10/8/2008 11:00:00 PM
The primary purpose of the Communication Plan is to establish discussion among all IEP team members who review the student’s needs based on communication skills and access. The Communication Plan should be the starting point for the IEP, and the results of this discussion should be used to identify the student’s present educational levels as well as to complete other sections of the IEP. The Annotated Communication Plan was revised in December 2010. Changes have been made to the following areas: annotation added for Section I, question 5; to Section III concerning the definition of qualified interpreters, and to the glossary to include definitions of qualified interpreters and communication modes and assistive technology devices and services for students who are deafblind. The revised version has December 2010 in the footer.
Age:School Age
Language:English
Preschool to School Age Transition Considerations for Children who are Deaf, Hard of Hearing or Deaf-Blind cover image

Preschool to School Age Transition Considerations for Children who are Deaf, Hard of Hearing or Deaf-Blind

Effective Date:10/31/2015 11:00:00 PM
Preschool to School Age Transition Considerations for Children who are Deaf, Hard of Hearing or Deaf-Blind
Age:School Age
Language:English
Authorization to Release Information for Infants/Toddlers with Hearing Concerns cover image

Authorization to Release Information for Infants/Toddlers with Hearing Concerns

Effective Date:5/20/2020 2:29:16 PM
A standard release form that will allow Early Intervention and the Department of Health to exchange information with a family of a child who is deaf or hard of hearing.
Age:Infant/Toddler
Language:English