Clone of Clone of Assessment Authorization (AA8) Form: Billing Form For Independent Evaluators

Assessment Authorization Billing Form for Independent Evaluators
Invoice No:
Last Name of Evaluator:*
Last Name Only
First Name of Evaluator:*
First Name Only
Social Security No:*
Last 4 Digits Only
Name of Agency (if applicable):*
* If "Other" List Name of Agency Here:
Employer Tax ID No.:
If applicable, (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*
Language of Assessment: 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*

ENSPARBGCNGKHEHIMNPJRUUDYIOther *
* If Other, specify language
If a language other than the options listed above, please type language of assessment here
Child's Admin School Information
CFN or CSE? Please check one*

CFNCSE
If CSE, please indicate CSE Number

01020304050607080910Charter School
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:
Should be Empty:

Assessment Authorization Billing Form for Independent Evaluators