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 51-60 of 86
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 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 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
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  cover image

Pennsylvania Medical Assistance Billing Parental Notice

Effective Date:11/1/2017 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. 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: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 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
PERMISSION TO EVALUATE - EVALUATION REQUEST FORM - School Age cover image

PERMISSION TO EVALUATE - EVALUATION REQUEST FORM - School Age

Effective Date:6/30/2008 11:00:00 PM
This form is effective beginning July 1, 2008 and reflects a new requirement of revised Chapters 14 and 711. This document must be issued by the Local Education Agency in response to a parent's oral request for an evaluation within 10 calendar days of the oral request.
Age:School Age
Language:English
Permission to Evaluate - Evaluation Request Form (Annotated) - School Age cover image

Permission to Evaluate - Evaluation Request Form (Annotated) - School Age

Effective Date:10/8/2008 11:00:00 PM
This annotated document describes the contents of the Permission to Evaluate - Evaluation Request Form, which is provided to the parent by the LEA upon a parent's oral request for an evaluation. This form provides the means of documenting the parental request in writing.
Age:School Age
Language:English
PERMISSION TO EVALUATE - Preschool Early Intervention cover image

PERMISSION TO EVALUATE - Preschool Early Intervention

Effective Date:1/1/0001 12:00:00 AM
This form is effective beginning March 2014. This form must be issued by the Local Education Agency to obtain written consent to conduct an initial evaluation.
Age:Preschool
Language:English