SELPA Referral Procedures
• 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
Must include diagnosis
o
o Must specify special health care need required
o Must specify medication type and dosage
o Must specify administration instructions
• Any additional supporting information
3.
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 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.
B.
Transfer Referral
1.
Pre-referral
Local Educational Agency (LEA) Responsibility
a) Complete the Transfer into LEA form (DM 52) and obtain the parent/guardian signature.
b) 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, if known. If not, leave the field blank.
CAHELP JPA Referral Procedures
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32
Revised 8/9/2022
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