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.
Bureau of Special Education Complaint Form
Access the State Complaint Form on PDE's State Complaints and Dispute Resolution page.
State Complaint Forms in other languages are also available on the State Complaints and Dispute Resolution page.
Complaint Resolution Procedures
If you need more information about the complaint process or if you are unable to print the packet and would like to receive a complaint form by mail, please contact the Special Educaton ConsultLine at 1-800-879-2301, ConsultLine@odr-pa.org or submit an online request.
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
Effective Date:11/1/2017 12:00:00 AM
This Arabic version of the 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. This form offers assistance and guidance to parents and Early Intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.
Age:Preschool,Infant/Toddler
Language:Arabic
Effective Date:11/1/2017 12:00:00 AM
This Chinese version of the 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. This form offers assistance and guidance to parents and Early Intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.
Age:Preschool,Infant/Toddler
Language:Chinese
Effective Date:11/1/2017 12:00:00 AM
This French version of the 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. This form offers assistance and guidance to parents and Early Intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.
Age:Preschool,Infant/Toddler
Language:French
Effective Date:11/1/2017 12:00:00 AM
This Nepali version of the 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. This form offers assistance and guidance to parents and Early Intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.
Age:Preschool,Infant/Toddler
Language:Nepali
Effective Date:11/1/2017 12:00:00 AM
This Portuguese version of the 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. This form offers assistance and guidance to parents and Early Intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.
Age:Preschool,Infant/Toddler
Language:Portuguese
Effective Date:11/1/2017 12:00:00 AM
This Russian version of the 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. This form offers assistance and guidance to parents and Early Intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.
Age:Preschool,Infant/Toddler
Language:Russian
Effective Date:10/31/2017 11:00:00 PM
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). Spanish Version.
Age:Infant/Toddler,Preschool
Language:Spanish
Effective Date:11/11/2017 2:47:25 PM
This form allows parents to choose whether to give consent to access reimbursement from Medical Assistance for Early Intervention/special education services. This form offers assistance and guidance to parents and Early Intervention providers. 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:Vietnamese
Effective Date:11/1/2017 12:00:00 AM
The PA MA Notice, Farsi version, allows parents to choose whether to give consent for the Local Educational Agency (LEA) to access reimbursement from Medical Assistance for special education services. This form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.
Age:Preschool,Infant/Toddler
Language:Farsi