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ADMINISTRATIVE LETTER
NO.: 5
POLICY CODE: IHBA
TO: Superintendents
of Schools and Directors of Special Education
FROM: J. Duke Albanese, Commissioner
Department
of Education
DATE: September 14, 2001
SUBJECT: EF-S-04A, State Agency Client
Admission/Discharge Notice
EF-S-04B,
State Agency Client Billing Form
Enclosed with this
Administrative Letter are copies of the EF-S-04A and EF-S-04B. These two forms are to be used to report the
admission or discharge of state agency clients to/from each school
administrative unit and when billing the Department of Education for special
education and related services provided to state agency clients by either a
school administrative unit or a private special purpose school. These forms will provide verification that a
student is a state agency client in the school administrative unit and
authorize payment for special education and related services provided to
special education children only. The
forms are available by e-mail or on the department’s web page at www.maine.gov/education/forms.htm. The enclosed tables have been changed
to reflect changes in the Maine Special Education Regulations, Chapter 101.
The EF-S-04A, State Agency
Client Admission/Discharge Notice, should be completed and mailed by each
school administrative unit to the Department of Education, Office of
Special Services, no later than October 1, 2001, for all state agency clients
enrolled as of the start of the school year. If you have no state
agency clients, it is not necessary to send in this form until the end of the
month when a state agency client enrolls in your unit.
The EF-S-04B, State Agency
Client Billing Form, should be sent to the Department of Education, Office of
Special Services, on a monthly basis,
for services provided to eligible students by your unit. BILLS FOR SEPTEMBER WILL BE DUE ON OCTOBER
18, 2001. Any bill received more than
thirty (30) days after the due date will be returned to the billing party and
will not be paid. An amendment was made
to the statute during the 1989 Legislative session which allows for
transportation to be billed as a related service to state agency clients when
this is specified in the student's IEP. (Table 4, Code 38)
ADMINISTRATIVE LETTER NO: 5
Page 2
The enclosed instructions
provide specific information as to when the EF-S-04B is due. The Office of Special Services will verify
that the students reported for billing were reported on the EF-S-04A prior to
authorizing payment and will notify the school administrative unit or private
school of any problems with processing the payment.
The initial submission of
the EF-S-04A will verify enrollment of all state agency clients as of the
beginning of the school year. The
EF-S-04A should be amended any time a change occurs in the status of any state
agency client included in the original report and a copy of the amended form
sent to the Office of Special Services at the end of the month in which any
changes occur. If no changes
occur during the month, you do not have to send an amended EF-S-04A.
Students who are eligible
state agency clients are defined as follows:
A. Department of Human
Services - Any student who is in the care or custody of DHS, residing in a foster
home, group home, or emergency shelter in the unit, and for whom special
education and/or related services are being provided;
B. Department of
Behavioral and Developmental Services (formerly Department of Mental Health and
Mental Retardation and Substance Abuse Services. - Any student who is placed in
a facility or with a person other than the child's parent, legal guardian, or
relative, with the approval of designated employee of Department of Behavioral
and Developmental Services, whose placement was made for other than educational
reasons and for whom special education and/or related services are being
provided; *
C. Department of
Corrections – Any student who is in the custody or under the supervision of the
Department of Corrections, including, but not limited to, a juvenile on
conditional release, an informally adjusted juvenile, a probationer or a
juvenile on aftercare status from the Maine Youth Center and who is placed, for
reasons other than educational reasons, pursuant to a court order or with the
agreement of an authorized agent of the Department of Corrections, outside the
juvenile’s home; and
D. Residents of state
institutions - Any student residing in a state institution who is attending
either a public school or a private special purpose day school, and for whom
special education and/or related services are being provided.
If there is a question about
the eligibility status of any student, school administrative units should
contact the appropriate state agency to determine whether the student qualifies
as a State Agency Client within the meaning of this statute. For further assistance, please contact
Christine Bartlett, Office of Special Services, at 624-6650.
JDA/CBB/pwo
* Reflects changes in
Department of Mental Health and Mental Retardation and Substance Abuse Services
name and their policy regarding what is an eligible state agency client.
ADMINISTRATIVE LETTER
NO.: 5
Page 3
GENERAL INSTRUCTIONS FOR
EF-S-04A
The EF-S-04A State Agency
Clients Admission/Discharge Notice is to be used for reporting all eligible
state agency clients who are residing in a school administrative unit
(SAU). Required data includes each
student's name, birthdate (month, day, year), gender, disability, state agency,
if state ward name and address of surrogate parent and yes or no to the
automatic foster parent appointment, educational placement, date of entry into
the SAU, discharge date upon leaving, and the SAU to which the student
transferred, if known. Amendments
should be submitted at the end of any month in which there is a change of status for any state
agency client included in the initial report or if a new state agency client
enters the SAU.
PAGE NUMBERING
If more than one page is
necessary, please duplicate the original form, number sequentially, and
indicate the total number of pages.
AMENDMENTS
When a state agency client
changes programs, or moves from one SAU to another, the EF-S-04A should be
amended to reflect the change which has occurred. If a new state agency client moves into the SAU, all appropriate
information must be added to the original report. For either of these events, provide all appropriate information,
check Amended Report in the upper
left hand corner, and submit a copy of the amended report to the Office of
Special Services at the end of the month in which the change occurred.
SPECIFIC INSTRUCTIONS FOR
EF-S-04A
Indicate the name of the
administrative unit, name of the person completing the form, and the telephone
number where that individual can be reached.
STUDENT INFORMATION
Identify each state agency
client using last name, first name, date of birth (month, day, year), gender
(M/F), exceptionality and the state agency(ies) with which the client is
affiliated, using the appropriate columns.
Table 1 provides the codes to be used for identifying
exceptionality; Table 2 provides
the codes to be used for identifying the State Agency(ies).
EDUCATIONAL PLACEMENT OF THE
STUDENT
Identify the name and level
(Elem., Middle, or Secondary) of the school attended, the type of placement
(see codes from Table 3), and any related services being provided (use
codes from Table 4) for each state agency client listed. Whenever the student's placement or program
changes, this must be noted on the form and an amended copy submitted to the
Office of Special Services as directed above, see AMENDMENTS.
ADMINISTRATIVE LETTER
NO.: 5
Page 4
DATE ENTERED/DATE DISCHARGED
Enter the date on which the
state agency client first enrolled in the SAU in the Date Entered column. Whenever a new state agency client enters
the SAU, all of the above information must be added to the form and the date
the student entered noted.
Whenever a state agency
client moves from one SAU to another, the date on which the client left the SAU
must be noted in the Date Discharged column and the SAU to which the client
moved noted in the last column, if known.
A copy of the amended form
must be submitted to the Office of Special Services at the last school day of
the month during which any changes in the status of state agency clients
occurred.
SIGNATURE AND DATE
Each copy submitted must be signed by the Superintendent of the SAU and dated. If more than one page is necessary, each page should be signed and dated.
ADMINISTRATIVE LETTER NO.:
Page 5
GENERAL INSTRUCTIONS FOR
EF-S-04B
The EF-S-04B State Agency
Clients Billing is to be used for billing the Office of Special Services,
Department of Education, for special education and related services provided to
eligible state agency clients by a school administrative unit or a private
special purpose school, in accordance with the student's IEP. Required data includes each student's name,
birthdate, gender, exceptionality, state agency, educational placement, dates
of service provided, related service charges and corresponding information,
total related services, tuition, and total of the two charges. The EF-S-04B should be mailed to the Office
of Special Services by Friday
of the first full week of the month following provision of special education
and related services. Any bill received more than thirty (30)
days after the service was provided will be returned to the billing party and
will not be paid. Amendments
must be submitted if there is an error in the information provided on the
original mailing of the form.
PAGE NUMBERING
If more than one page is necessary, please duplicate the original form, number sequentially, and indicate the total the number pages. Record the total of all charges at the end of the final page.
AMENDMENTS
If an error is made in any
of the information provided, the EF-S-04B must be amended to reflect the
correct information and a copy of the amended EF-S-04B submitted to the Office
of Special Services. Please check the Amended Report box in the upper
left hand corner of the form. Amended reports must be received in the
Division no later than June 15 for the fiscal year being billed. Amended reports received after this date
will not be paid.
SPECIFIC INSTRUCTIONS FOR
EF-S-04B
Indicate the name of the
administrative unit or private special purpose school, name of the person
completing the form, and the telephone number where that individual can be
reached.
STUDENT INFORMATION
Identify each state agency
client using last name, first name, date of birth (month, day, year), gender
(M/F), exceptionality and the state agency(ies) with which the client is
affiliated, using the appropriate columns.
Table 1 provides the codes to be used for identifying the
exceptionality; Table 2 provides the codes to be used for identifying
the State Agency(ies).
EDUCATIONAL PLACEMENT OF
STUDENT
Identify the name and level
(Elem., Middle, Secondary) of the school attended, the type of placement (use
codes from Table 3), and any related services being provided including transportation, if included in the student's IEP (use
codes from Table 4). List all
services for which a charge will be made for each state agency client
listed. If the student's placement
changes, note on the next form submitted.
ADMINISTRATIVE LETTER
NO.: 5
Page 6
DATES OF SERVICE PROVIDED
Provide the dates (month,
day, year) when service began and ended during the month for which the bill is
being submitted for each eligible state agency client listed. For students who were enrolled in the
program for the entire month, use beginning and ending dates for the billing
period. For students who either entered
after the start of the billing period, or left prior to the end of the billing
period, provide the date the student actually entered as the first date, or the
date the student actually left as the last date entered.
RELATED SERVICES
Enter separately the actual
monthly cost of each related service provided to each eligible student. The cost/student should be determined by
dividing the total cost of the service by the total number of units of service
provided (e.g., hours of therapy). Multiply the cost/unit by the actual number
of units of service provided to the eligible student during that billing
period, and enter this amount in the column Related Services. Transportation
is considered for billing purposes as a related service, if specified as such
in the student's IEP.
TUITION CHARGE
Enter the actual monthly cost for each client's special education classroom
placement in the column marked tuition.
Private schools should enter the approved monthly rate as established by
the Department, pro-rated to reflect the actual number of days served, if the
client entered or was discharged without attending for the full month being
billed. School administrative units
should determine the actual tuition cost according to Title 20-A, M.R.S.A.,
sub-Chapter III, ss 7302, and Maine Special Education Regulations, C.101.19. 3.
(or 19.4., if a new program).
TOTAL OF TUITION AND RELATED
SERVICES
For each student, add the tuition
column and the total related service(s) charge column and enter the total in
this column.
TOTALS
For each page submitted,
total all tuition charges at the bottom in the appropriate column, all related
service charges, and the total of all costs.
If more than one page is submitted, total all pages and enter this
figure at the bottom of the last page submitted.
SIGNATURE AND DATE
Each copy submitted must be
signed by the Superintendent of the school administrative unit or the Director
of the private school submitting the bill.
Each page must also be dated.
TABLE 1
EXCEPTIONALITY
(USE ONE CODE ONLY)
CODE:
1. Mental
Retardation
2. Hearing
Impairment
3. Deafness
4. Speech and
Language Impairment
5. Visual
Impairment including blindness
6. Emotional
Disability
7. Orthopedic
Impairment
8. Other Health
Impairment
9. Specific
Learning Disability
10.
Deaf/Blindness
11. Multiple
Disabilities
13. Autism
14. Traumatic Brain Injury
15. Non-Special
Education
TABLE 2
STATE AGENCY CODES
(USE AS MANY CODES AS
NECESSARY)
CODE:
20. Department of Behavioral and Developmental Services (formerly Department of Mental Health, Mental Retardation and Substance Abuse Services), student with Mental Illness/Behavior Impairment
21.
Department
of Behavioral and Developmental Services (formerly Department of Mental Health,
Mental Retardation and Substance Abuse Services, student with Mental
Retardation
22.
Department
of Human Services
23.
Department
of Corrections
24.
Residents of State Institutions
REPORT OF SERVICES TO
EXCEPTIONAL STUDENTS
TABLE 3
CONTINUM OF SPECIAL
EDUCATION PLACEMENTS
NOTE:
THIS TERMINOLOGY IS DERIVED FROM FEDERAL REPORTING REQUIREMENTS AND DOES NOT
IMPLY A CHANGE IN MAINE REGULATIONS OR DEFINITIONS
CODE:
21. Regular
Class where a
student with a disability receives a majority of his/her
education and related services OUTSIDE THAT
CLASSROOM for less than 21 percent of the school day. This may include
students with disabilities placed in:
regular class with special education/related services provided within
the regular class, or regular class with instruction within the regular class
and with special education/related services provided outside the regular
class. Students receiving monitoring
services should also be included in this category.
22. Resource Room where
a student with a disability receives special education and
Placement: related
services OUTSIDE THE REGULAR CLASSROOM for 60 percent or less of the
school day and at least 21 percent of the school day. This may include students with disabilities placed in: resource rooms with special education/related
services provided within the resource room, or resource rooms with part-time
instruction in a regular class.
23.
Self-Contained where a student
with a disability receives special education and related
Placement: services
OUTSIDE THE REGULAR CLASSROOM for more than
60 percent of the school day in a self-contained program. This may include students with disabilities placed in: self-contained special classrooms with part-time instruction in a regular class, or self-contained special classrooms full-time.
24.
Public where a student with a disability receives special
education and related
Separate Day services for greater than 50 percent of the school day in
public separate
School day school facilities.
Placement:
25.
Private where a student with a disability receives special
education and related
Separate Day services for greater than 50 percent of the school day in
private separate
School day school facilities.
Placement:
26.
Public where a student with a disability resides and receives
special education
Residential and related services for greater than 50 percent of the
school day in
Placement: public residential
facilities.
27.
Private where a student with a disability resides and receives
special education
Placement: in private
residential facilities.
28.
Homebound where a student with
a disability receives special education and
Hospital related services in a medical
treatment facility or at home.
Placement:
SUPPORTIVE SERVICES
(USE AS MANY CODES AS
NECESSARY)
Definitions of these related
services can be found in 34 CFR 300.16.
Diagnostic Services should
be reported under the appropriate related service code.
CODE:
31. Psychological
Services
32. School Social
Work Services
33. Occupational
Therapy
34. Speech and
Language Services
students with
speech/language
impairment (Table I, Code 4)
as their primary
exceptionality.
35. Audiological
Services
36. Recreational
Services
37. Physical
Therapy
38.
Transportation Services (special transportation arrangements)
39. School Health
Services
40. Counseling
Services
41.
Other
Related Services (please specify)