Date: / Fax back to school at:

NOTICE OF NEEDFOR A PERSONAL CARE ASSISTANT

Dear (Physician’s Name):

District 287 is an intermediate school district that provides special education programs to many students in Hennepin County. All school districts in Minnesota are required to seek payment from public and private health insurance providers for some of the individual educational plan (IEP) health related services they provide to students. One of these services is Personal Care Assistance (PCA). In order to receive reimbursement from Medical Assistance/MinnesotaCare for this service, schools are required to annually notify a primary care provider.

This patient of yours is currently enrolled in one of our special education programs and has an IEP that addresses the need for Paraprofessional/PCA service during the school day in areas identified below.

Pleasereview the following summaryon this patient, sign the bottom of this form to indicate that you have received this information, and FAX it back to us at the number indicated above. If you have questions regarding third party reimbursement for IEP health related services in District 287, you may call Lois Lillie at 763-550-7171.

Student Name: / DOB:

This student has the following diagnosis/educational disability:

Deaf/Hard of Hearing / Developmental Cognitive Disability
Blind/Visually Impaired / ADHD
Physically Impaired / Emotionally/Behaviorally Disturbed
Autism Spectrum Disorder / Seizure Disorder
Traumatic Brain Injured / Tourette Syndrome
Other

As part of his/her individual educational program at District 287, this student needs a PCA (paraprofessional) during regular school attendance days to provide assistance, monitoring or prompting with the following activities:

Transfers and Mobility / Application of hearing aids
Turning and Positioning / Intervene of seizures
Dressing and Undressing / Assistance with self administered mediations
Eating/Food Prep/Feeding / Redirection/Intervention for Behaviors involving
Toileting/Bowel & Bladder care / Increased vulnerability
Grooming and Hygiene / Injury to self
Range of Motion/Muscle Strengthening / Injury to others
Application of orthotics/prosthetics / Damage to/destruction of property
Other

If you have questions regarding this student’s educational needs, please contact:

Program Facilitator or Educational Case Manager Telephone #

*Physician signature:

(this signature indicates notice of need for PCA service in school has been received)

Form updated 7/1/2012