Pennsylvania Child Participation Form

Complete this form to enter new eligible SBAP students. Leader will add this information to its claims processing database and use the information to preprint your LEA’s Service Description Slips. Use the blank area at the bottom of the Service Provider Information section to enter a service specialty that is not listed. Please mail or fax completed forms to Leader Services at the PO Box address or fax number listed below.

STUDENT INFORMATION
EDUCATION AGENCY NAME	LEA STUDENT TRACKING NUMBER - Optional	DATE
STUDENT NAME	Last First MI	STUDENT’S BIRTH DATE (mm-dd-yy)
STUDENT’S SOCIAL SECURITY NUMBER	GENDER	ACCOUNTING UNIT NUMBER (AUN) - Optional
M F
MEDICAL ASSISTANCE (MA)

ID NUMBER - 10 DIGITS
SERVICE PROVIDER INFORMATION
SERVICE SPECIALTY	SERVICE PROVIDER NAME	SCHOOL BUILDING (optional)
SPEECH, LANGUAGE AND
HEARING SERVICES	1)
2)
PHYSICAL THERAPY	1)
2)
OCCUPATIONAL THERAPY	1)
2)
NURSING SERVICES – REGISTERED	1)
2)
NURSING SERVICES –

LICENSED PRACTICAL	1)
2)
PERSONAL CARE
ASSISTANT SERVICES	1)
2)
ONGOING
PSYCHOLOGICAL SERVICES	1)
2)
TEACHER HEARING
IMPAIRED	1)
2)
ONGOING

SOCIAL WORK SERVICES	1)
2)
1)
2)

U.S. Postal Service Address

PO Box O

Hazleton PA 18201	Package Delivery Address

75 Kiwanis Boulevard

West Hazleton PA 18202	Phone: (800) 360-8511

Fax: (570) 455-4526

Web site: www.leaderservices.com
DRSPA0013E0030704LS

Child Participation Form

Child Participation Form

Leader Services

Leader Services

Leader Services

2001-07-30

Charles Zaremba

Leader Services

Leader Services

Leader Services