6. LEAs are encouraged to have assessment plans signed close to the date of their LEA audiology evaluation date and within the required 60-day assessment time frame. 7. Complete the Authorization for Use and/or Disclosure of Information form (D/M 63) and obtain the parent/guardian signature. Specify the receiving agency’s name as the SELPA/Pacific Hearing Services. The disclosing agency will vary depending on whether it is a physician, medical center, or audiologist. Referral Procedures Forward the following completed documents to the attention of the Area Director for Desert/Mountain Operations (DMOPS). • D/M 108 Initial Request for Audiological Evaluations/Services form • D/M 66 Assessment Plan form • D/M 63 Authorization for Use and/or Disclosure of Information form • IEP or IEP Addendum dated within one year of the referral for an audiological assessment • LEA’s hearing screening form that documents a minimum of two repeated failures on threshold tests or previous audiological assessment reports and/or audiograms for students who have an identified hearing loss. (This does not apply to Desert/Mountain Operations) 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 (D/M 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 SELPA Audiological Program. The calendar can be found on the SELPA website at www.dmselpa.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 Desert/Mountain Children’s Center (DMCC), or at the service provider’s office, whichever is available and appropriate. Please contact the CAHELP Chief Executive Officer at the SELPA for assistance. Timeline for Services Upon completion of the audiological assessment, a written report will be sent to the Area Director for Desert/Mountain Operations (DMOPS). DMOPS will electronically send a copy of the cover letter and the report to the LEA director of special education and a copy to the director’s secretary and LEA Coordinator for Audiology Services. DMOPS will upload a copy of the cover letter to
Chapter 22 – Supports and Services, Charter SELPA As of 10/17/2019 D/M Charter SELPA Steering Committee Approval
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