School-Age Request For Reimbursement For Full-Time 1:1 Aides, Part-Time/shared 1:1 Aides And 1:1 Rn, 1:1 Lpn, 1:1 Interpreters F/t Deaf

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NEW YORK STATE EDUCATION DEPARTMENT
STAC AND MEDICAID UNIT
SCHOOL-AGE REQUEST FOR REIMBURSEMENT FOR
1:1 EDUCATION AIDES (other than full or half-time) and,
ALL 1:1 MAINTENANCE AIDES, RNs, LPNs, and INTERPRETERS f/t DEAF
STAC ID# :
(if known)
Student Name:
Date of Birth:
Education Provider:
School Code:
Program Name:
Program Code:
Type: Part-Time Aide
RN _____
LPN_____
Interpreter f/t Deaf
Is this 1:1 Aide/Nurse/Interpreter Shared? No
Yes
No. of Students Sharing the 1:1
_
Component:
Education Only
Maintenance Only
Education & Maintenance
__
1:1 FOR EDUCATION:
Requested Start Date of 1:1:
/
/
Projected End Date of 1:1:
/
/
Hours Per Day Program Runs:
Hours Per Day Student Attends
Days Per Week Student Attends
1:1 Hours Per Day Requested:_
1:1 Days Per Week Requested:_
District of Residence/District of Service Assurance
I have reviewed the above named student’s records and assure that the student’s Individualized Education Plan (IEP) specifically
requires that a 1:1 Aide/Nurse/Interpreter be provided for the period indicated above.
CSE Responsible School District
CSE SED District Code
Date
Signature of Superintendent of Schools (NYC- Superintendent of Clinical Services)
1:1 FOR MAINTENANCE:
Report the following for the maintenance portion only of a CSE placed student in either an eligible in-state or out-of-state 853
residential facility, excluding Children’s Residential Project (CRP) Programs.
Requested Start Date of 1:1:
/
/
Projected End Date of 1:1
/
/
Hours of Service/Days of Service
School Days (M-F):
hrs./ 5 days
Non-School Days (S-S):
hrs./ 2 days
Salary and Fringe Benefits per hour:
$
******************************************************************************
Approved:
Date:
SED USE ONLY
Contact Person:
Phone #: (
)
Fax #: (
)
E-mail Address:
Revised Nov 2016

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