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PURCHASE OF SERVICES: REFERRAL AND AUTHORIZATION <br />I. REFERAL TO COUNTY DEPARTMENT OF SOCIAL SERVICES <br />Please determine the need and eligibility of the fallowing Individual for <br />I rom <br />Re1wred by <br />11. CLIENT INFORMATION <br />A. Individual to Fewive Service (s) <br />Address <br />Telephone <br />Birth oate <br />Res;M Sible Adult (if Other than aboval <br />Date Agency <br />service I[ <br />prow 10& <br />111. AUTHORIZATION <br />A. The provider (is) is not, authorized to claim retmtxerSsment for services provided to the individual nrreld •t+�e• 19� <br />B. Service is authorized from 19 through <br />C. Purchase Program I Dn <br />D. Authorization Terminated Effective . 19 <br />IV. SERVICE INFORMATION <br />A. The provider is authorized to claim reimburser*ter+t in accordance with the Purchase of Swrvice Contract for the following <br />services provided to the Individual namea above: <br />Service Coda <br />. fee a <br />per unit: <br />effective: <br />Service Cone <br />fee s <br />per unit: - <br />effective: <br />Service Code <br />fee S <br />per unit: <br />effective: <br />Service Gods <br />fee 5 <br />per unit: <br />effective. <br />- <br />B (To be completed if Child Day Care Services are authorized in Section IVA). As part o{ the Child Day Core Services author zed <br />Section IVA. svpplemental needs services (are) (ore not) authorized for reimbursement at the suppiementol needs payment ro+e- <br />V. ELIGIBILITY INFORMATION <br />A. Individual category of eligibility code <br />B. R>bcipient IOI: <br />DEPARTMENT OF SOCIAL SEFIVIC£S <br />TELEPHONE: <br />SERVICE WORKER <br />Signature of Autnortzed County Representative Date <br />055.1360 (Rev. 7/25) <br />Family Serv-ces <br />County Identifier <br />IN REP T. REFER TO: <br />County Case Numtser <br />