Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
LEAs are encouraged to have the Assessment Plan signed close to the date of their LEA audiology evaluation date and within the required 60-day time frame. 3. Complete the Authorization for Use and/or Disclosure of information form (DM 63) and obtain the parent/guardian signature. Specify the receiving agency’s name as the SELPA/DMOPs/Pacific Hearing Services. The disclosing agency will vary pending on whether it is a physician, medical center, or audiologist. B. Referral Procedures Forward the following completed documents to the attention of the Area Director for DMOPS: • DM 108A – Annual Request for Audiological Evaluation/Services • DM 66 – Assessment Plan • DM 63 – Authorization for Use and/or Disclosure of Information C. Timeline for Assessment The audiological assessment must occur within 60 calendar days from the date the Assessment Plan was received by the LEA. When the signed Assessment Plan is received by the LEA, it should be date stamped or the date entered in the field at the bottom of the Assessment Plan (DM 66). An Audiology Assessment Calendar is published on an annual basis at the beginning of each school year. The calendar lists the scheduled assessment dates and referral due dates for each LEA within the SELPA that participates in the Audiological Program. The calendar can be found on the CAHELP website at www.cahelp.org. For students who require services outside of the regularly scheduled LEA visit, services may be coordinated between the SELPA and the LEA. Arrangements may be made for students to be served at the school site, at a nearby LEA, the DMCC, or at the service provider’s office, whichever is available and appropriate. Please contact the CAHELP Chief Executive Officer at the CAHELP for assistance. D. Timeline for Services
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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