Medical Practitioner Authorization for SBAP Services
Student’s name:

I reviewed the Individualized Education Program (IEP) for this student and agree that the following evaluations and health-related services recommended by the IEP team are both appropriate and medically necessary.
Date of the current IEP meeting:
Month / day / year
Evaluations included in this IEP
Audiology
Occupational Therapy
Orientation and Mobility
Physical Therapy
Psychiatric
Psychological
Social Work
Speech/Language
Related Services
Frequency
Projected

Start Date
Anticipated Duration
Audiology
Nursing
Occupational Therapy
Orientation and Mobility
Personal Care Assistant
Physical Therapy
Psychiatric
Psychological
Social Work
Special Transportation
Speech/Language
Hearing Impaired
Authorized Signature:
Authorized Date:
Practitioner Title:
Start Time:	End Time:	Total Review Time
No. of minutes
A School or Licensed Psychologist can recommend and authorize psychological services only.

A Licensed Social Worker, Licensed Professional Counselor, or Licensed Family Counselor can recommend and authorize social work services only.

Authorized Date is the Authorized Billing Date for all services listed above.

www.leaderservices.com/pa ( sbap@leaderservices.com ( SBAP support: (800) 360-8511
© 2012 Leader Services [PA1212]

Medical Practitioner Authorization for SBAP Services

fbloss

2012-12-21