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ATTACHMENT I <br />PURCHASE OF SERVICES: REFERRAL AND AWHORIZATION <br />1. REFERRAL TO COUNTY DEPARTMENT OF SOCIAL SERVICES <br />Please determine the need and eligibility of the following individual for <br />from <br />sery ice I s► <br />provider. <br />Referred by Date <br />11. CLIENT INFORMATION <br />A. Individual to Receive Service is) <br />Address <br />Telephone <br />Birthdate <br />Responsible Adult (if other than above) <br />Agency <br />111. AUTHORIZATION <br />A. The provider (isl (is not) authorized to claim reimbursement for services provioW to the individual named above. <br />B. Service is authorized from 19 through <br />C. Purchase Prograrm Ion <br />D. Authorization Terminated Effective 19 <br />. 19 I <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 />V. <br />Service Code <br />fee $ <br />per unit' <br />effaeti ve: <br />_ <br />Service Code <br />fee s <br />Per unit: <br />effective: <br />Service Code <br />fee S <br />per unit: <br />effective: <br />Service Code <br />fee S <br />per unit: <br />effective: <br />B (To be completed if Child Day Core Services are authorized in Section IVA). As port of the Child Day Care Services authorized in I <br />Section IVA, supplemental needs services (ore) (ore not) authorized for reimbursement of the supplemental needs payment rate. <br />ELIGIBILITY INFORMATION <br />A. Individual category of eligibility code <br />B. Recipient ION <br />DEPARTMENT OF SOCIAL SERVICES <br />SERVICE WORKER <br />Signature of Authorized County Representative <br />DSS -1360 (Rev. 7/85) <br />Family Services <br />Date <br />LffW:1 Z I•M:; <br />County Identifier <br />IN REPLY, REFER TO: <br />County Case Number <br />