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ATTACHMENT I 28 <br /> PURCHASE OF SERVICES: REFERRAL AND AUTHORIZATION <br /> a . <br /> I. REFERRAL TO COUNTY DEPARTMENT OF SOCIAL SERVICES <br /> Please determine the need and eligibility of the following individual for • <br /> service 151 <br /> Irom provider. <br /> Referred by Date Agency <br /> II. CLIENT INFORMATION <br /> A, Individual to Receive Service(s) <br /> Address <br /> Telephone <br /> Bi rt'hdate <br /> Responsible Adult (it other than above) <br /> It). AUTHORIZATION <br /> A. The provider (is) (is not) authorized to claim reimbursement for services provided to the individual named above. <br /> B. Service is authorized from , 19 through , 19 <br /> C. Purchase Program I De <br /> D. Authorization Terminated Effective , 19 <br /> IV. SERVICE INFORMATION <br /> A. The provider is authorized to claim reimbursement in accordance with the Purchase of Service Contract for the following <br /> services provided to the individual named above: <br /> Service Code _ fee $ per unit: effective: <br /> Service Code fee $ per unit:, effective: <br /> Service Code fee $ per unit: effective: <br /> Service Code fee s per unit: effective: <br /> B (To be completed if Child Day Core Services ore authorized in Section IVA). As port of the Child Day Core Services outhorized in <br /> Section IVA, supplemental needs services (ore)(are not) authorized for reimbursement at the supplemental needs payment rote. <br /> • <br /> V. ELIGIBILITY INFORMATION <br /> A. Individual category of eligibility code <br /> B. Recipient IDN <br /> DEPARTMENT OF SOCIAL SERVICES. <br /> SERVICE WORKER TELEPHONE:. <br /> Signature of Authorized County Representative Date County Identifier <br /> IN REPLY, REFER TO:, County Case Number <br /> DSS•1360(Rev. 7/85) <br /> Family Services <br />