Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
signature. Specify the receiving agency’s name if known. If not, leave the field blank.
B. Referral Procedures Forward the following documents to the attention of the Program Manager for Resolution Support Services at the SELPA. • DM 148 – Special Health Care Services Referral • DM 63 – Authorization for Use and/or Disclosure of Information • IEP or IEP Addendum dated within one year of the referral for special health care services. • Psycho-educational evaluation dated within three years of the
referral for special health care services. • Current Summary of Treatment Plan
o Must be signed by physician and parent/guardian. o Must include diagnosis. o Must specify special health care need required. o Must specify medication type and dosage. o Must specify administration instructions.
• Any additional supporting information.
C. Timeline for Services Within five business days of receipt of the completed referral packet, the Program Manager for Resolution Support Services at the SELPA will develop an ISA and forward it to the appropriate NPA for signature. Upon receipt of the signed ISA, the SELPA will forward the referral packet to the appropriate NPA. The agency will contact the person who signed the referral to coordinate and begin services. The SELPA will enter the services into the IEP system.
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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