Pennsylvania Service Description Slip
Pennsylvania Service Description Slip
|[pic] | |
|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 |
| |
| | |YELLOW COPY – SBAP COORDINATOR | |PINK COPY – SERVICE PROVIDER | |
|WHITE COPY – BILLING OFFICE | | | | | |
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