2018-20189 Assessment Authorization/Independent Agreement (AA8) Form

2018-2019 Assessment Authorization/Independent Agreement Billing Form For Independent Evaluators
ATTENTION:

This form is no longer active.

For all Authroized Assessments/Independent Agreement/Resolution or Impartial cases;2019-2020 Assessment Authorization/Independent Agreement Billing Form

Invoice No:
Optional: (For your internal use)
Last Name of Evaluator:*
Last Name Only
First Name of Evaluator:*
First Name Only
Social Security No:*
Last 4 Digits Only
Please choose from the DROP DOWN. ONLY USE OTHER IF YOU DO NOT SEE YOUR AGENCY NAME.
Name of Agency (if applicable):*
* If "Other" List Name of Agency Here:
If Other=List Agency Name, If Non Applicable =List Provider Name that check is to be made payable to
Employer Tax ID No.:*
No dashes please
Student Last Name:*
Last name only
Student First Name:*
First name only
OSIS/NYC ID#:*
No dashes please
Child's Date of Birth*

MonthDayYear
Type of Assessment: *
- 01=Neurological (Only)
- 02=Psychiatric
- 03=Psychoeducational
- 04=Speech
- 05=Audiological
- 06=Visual
- 07=Medical
- 09=OT
- 10=PT
- 11=Social History
- 14=Neuropsychological
- 25=Assistive Technology
- 26=CAPD
- 27=Interpreter
- 28=Feeding
- 29=Functional Behavioral Analysis
Language of Assessment: *

ENSPARBGCNGKHEHIMNPJRUUDYIOther *
- EN=English
- SP=Spanish
- AR=Arabic
- BG=Bengali
- CN=Cantonese
- GK=Greek
- HE=Hebrew
- HI=Hindi
- MN=Mandarin
- PJ=Punjabi
- RU=Russian
- UD=Urdu
- YI=Yiddish
- Other=not on list, need to specify
* If Other, specify language
If a language other than the options listed above, please type language of assessment here
Child's Admin School Information
All Public and D75 Schools are BFSC, Private School, Home Schooled and Charter Schools are CSE.
BFSC or CSE? Please check one*

BFSCCSE
If CSE, please indicate CSE Number

01020304050607080910
Admin DBN/School Name*
Use 6 digit number/letter/number DBN (District,Borough,Number) ex. 29Q135,09CS01,10XAES
Service District Number*
Date of Assessment*

MonthDayYear
Date of Report Recieved by ISC/CSE Designee:
Rate for Evaluation: $*
Please Enter Your Rate Here
Signature of Independent Evaluator
Date
**The report has been reviewed and is acceptable.**
Signature of DOE Responsible Party
Date
FOR OFFICE USE ONLY
Date received by ISC/CSE Designee:
Date submitted to Bureau of Non-Public School Payables:
Is this a Resolution Agreement or Impartial Case?*

YesNo
UPLOAD YOUR SUPPORTING BILLING DOCUMENTATION TO THIS FORM

YOU NO LONGER NEED TO EMAIL YOUR SUBMISSIONS. Upload the forms directly here instead.
- For Assessment Authorization (AA) Referrals:
  - Upload AA8 & AA2 forms
- For Resolution or Impartial Hearing Cases:
  - Upload Resolution/Impartial Paperwork along with AA2 (if applicable) & AA8 (or private invoice on letterhead)
- For Interpretation Agencies:
  - Upload AA8 (or private invoice on letterhead)
Upload supporting billing documentation here*

Upload a File
PLEASE DO NOT INCLUDE SPECIAL CHARACTERS LIKE PERIODS, COMMAS, EXCLAMATION POINTS, ETC IN YOUR FILE NAME Cancelof
**Please Note - You must keep the ORIGINAL FORMS (AA2, AA8, Impartial/Resolution forms, etc.) on file for 7 years**
Please enter your contact email here*
Required entry
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2018-2019 Assessment Authorization/Independent Agreement Billing Form For Independent Evaluators