| Service Provider Update Form. Please click on the link below. PDF format. |
| Special Incident Report. Please click on the link below. SIR in Word 2003 format. SIR in PDF format. |
EFT-Direct Deposit: Form PDF format
Complete form and return to [email protected] with a voided check copy or bank document for verification. |
Parental Verification for Receipt of Behavioral Services.This form is to be used for:
| Crisis Team-Evaluation and Behavioral Intervention |
017 |
| Tutor Services Group |
025 |
| Client/Parent Support Behavior Intervention Training |
048 |
| Parent-Coordinated Home Based Behavior Intervention Program for Autistic Children |
077 |
| Adaptive Skills Trainer |
605 |
| Behavior Analyst |
612 |
| Associate Behavior Analyst |
613 |
| Behavior Management Assistant |
615 |
| Behavior Technician Paraprofessional |
616 |
| Behavior Management Consultant |
620 |
| Counseling Services |
625 |
| Tutor |
680 |
BIS Billing Form (PDF Format) BIS Billing Form – Spanish (PDF Format) |
Home Billing Form.This form is to be used by vendors in the following categories:
| Early Start Specialized Therapeutic Services |
116 |
| Speech Therapy |
707 |
| Physical Therapy |
772 |
| Occupational Therapy |
773 |
Home Billing Form (Word Format) Home Billing Form (PDF Format) |
| Day Care Billing Form.(PDF Format)
|
Interpreter/Translator Service Time Sheet. This form is to be used by vendors in the following categories:
| Interpreter (Sign) |
642 |
| Translator (all other languages) |
643 |
Instructions for completing Time Sheet (Word Format) Interpreter/Translator Service Time Sheet (PDF Format)
|
| Patch Funding Sheet. This form is to be used by Residential, Day Program, and Other Vendors to document their billing for Supplemental Program Support, sometimes referred to as "Patch" Funding, which is supplemental staffing on a time-limited basis for a specific consumer. PATCH Funding Sheet (Excel Format) PATCH Funding Sheet (PDF Format) |
