1. Convene an Individualized Education Program (IEP) meeting to document the team’s decision to refer the student for special health care services. 2. Complete the Special Health Care Services Referral form (D/M 148) and obtain the signatures of the person making the referral and the director of special education. 3. 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, if known. If not, leave the field blank. Referral Procedures Forward the following documents to the attention of the Program Manager for Resolution Support Services at the SELPA. • D/M 148 Special Health Care Services Referral 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 special health care services • Psycho-educational evaluation dated within three years of the referral for special health care services • Current Summary of Treatment Plan Must be signed by physician and parent/guardian Must include diagnosis Must specify special health care need required
Must specify medication type and dosage Must specify administration instructions Any additional supporting information
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 Individual Service Agreement (ISA) and forward it to the appropriate Nonpublic Agency (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 SELPA Management Information System (MIS) database.
Chapter 22 – Supports and Services, Charter SELPA As of 10/17/2019 D/M Charter SELPA Steering Committee Approval
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