Pennsylvania Service Description Slip

Education Agency Name

Service Month/Year

Student Name (Last, First, MI)

Date of Birth

Service Provider

School Building

Service Specialties
1. Individual Services
2. Group Services
Please check (x) the appropriate service specialty
Please enter the total number of hours and minutes per day
01	Audiology
Day	Hours	Minutes
Day	Hours	Minutes
02	Nursing (RN)
1
1
03	Occupational Therapy
2
2
04	Personal Care Assistant
3
3
05	Physical Therapy
4
4
06	Physician
5
5
07	Psychiatric
6
6
08	Psychology
7
7
09	Social Work
8
8
10	Speech/Language/Hearing
9
9
11	Vision
10
10
12	Orientation & Mobility
11
11
13	Teacher of the Hearing Impaired
12
12
14	IEP
13
13
15	Nursing (LPN)
14
14
15
15
Signatures
16
16
17
17
18
18
Service Provider’s Signature
19
19
Date	/ /
20
20
21
21
22
22
Supervisor’s Signature
23
23
(required when services are provided by paraprofessionals)
24
24
Date	/ /
25
25
26
26
27
27
28
28
29
29

(800) 360-8511	U.S. Postal Service Address

PO Box O

Hazleton PA 18201	Package Delivery Address

75 Kiwanis Boulevard

West Hazleton PA 18202
30
30
31
31
WHITE COPY – BILLING OFFICE
YELLOW COPY – SBAP COORDINATOR
PINK COPY – SERVICE PROVIDER

Pennsylvania Service Description Slip

Pennsylvania Service Description Slip

Leader Services

Leader Services

Leader Services

2008-10-14

Charles Zaremba

Leader Services

Leader Services

Leader Services