PROCEDURAL HANDBOOK - SBCSELPA



Santa Barbara County

Special Education Local Plan Area ___________A Joint Powers Agency

OT PHYSICIAN’S COVER LETTER

|TO: |THE PHYSICIAN OF: |       |DATE: |       |

FROM: SANTA BARBARA COUNTY SPECIAL EDUCATION LOCAL PLAN AREA (SELPA)

RE: PHYSICIAN'S INFORMATION FOR RELATED SERVICES

Information is being requested because this child has been referred for an Occupational Therapy evaluation by his/her school district. The child may need Occupational Therapy services in order to benefit from his/her special education program and/or he/she may have deficits in motor abilities that are related to a suspected area of disability. State law requires school districts to determine whether a child should be referred to California Children Services (CCS) to be assessed for the determination of medically necessary occupational therapy services. For this reason, we require information on whether this child has a CCS Medical Therapy Program eligible diagnosis. If the child does not qualify for CCS Medical Therapy Program, he/she still may be evaluated for Occupational Therapy services through the educational program.

This referral is not to be considered a prescription. It is a request for medical information regarding any identified diagnosis, contraindications, precautions or medications that may be related to assessment and/or the provision of Occupational Therapy services. For your records, enclosed is a signed Consent for Release of Information.

Educational agencies are bound by law to process referrals within a specified timeline. Your prompt response will be most appreciated.

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|Administrator/Case Manager, Special Education Services |

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|District |

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|Street Address or PO Box |

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|City, State, and Zip Code |

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|Phone Number |

Attachments:

Physician's Form for Related Services

Signed Parent Consent for Release of Information

SELPA 6 (2-1-2010)

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