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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