Rsa 7A Form – Fill Out and Use This PDF

The RSA-7A form, officially known as the Billing Form for Independent Providers of Related Services, is a critical document used to record and submit billing information for educational services provided outside the traditional classroom setting. Created under the direction of Christopher McKay, the form is a necessary tool for independent service providers to invoice for student-specific services, as outlined in their Individualized Education Program (IEP). Ensure accurate and timely compensation for your valuable services by filling out the RSA-7A form. Click the button below to get started.

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Rsa 7A Form PDF Details

The RSA-7a Billing Form for Independent Providers of Related Services plays a pivotal role in the documentation and reimbursement process for educational services provided outside the traditional public school system. Created by the Bureau of Non-Public School Payables under the leadership of Director Christopher McKay, this comprehensive document ensures that independent providers can accurately report and invoice for the specialized educational services they offer. The form encompasses several crucial sections, starting with detailed student information including their name, New York City Identification number, date of birth, service district, and the specific related service provided, aligning with the student's Individualized Education Program (IEP) recommendations. Additionally, it captures provider and agency information, crucial for processing payments, including addresses, contact numbers, and tax identification numbers. Service provision is meticulously recorded, documenting the frequency, duration, group size, and session timing to accurately reflect the service delivered. The form culminates in a certification section that requires the signatures of the provider and a parent, principal, or guardian, affirming the accuracy of the information provided and acknowledging the legal and ethical obligations tied to the submission of this information. This form is not just a billing document; it serves as a binding agreement verifying the provision of services, making it an essential tool for maintaining transparency, accountability, and integrity in the provision of related educational services.

Question	Answer
Form Name	Rsa 7A Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	rsa 2020, form rsa 7, independent providers of related service billing form rsa 7a, rsa form

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Christopher McKay, DIRECTOR

Bureau of Non-Public School Payables

RSA-7a Billing Form for Independent Providers of Related Services (RSA) Vendor Invoice # ____________________ Month: _____________ Year: ____________

Section 1: Student Information

Student's Name: ___________________________________

LastFirst

NYC ID #: __ __ __- __ __ __ - __ __ __

Date of Birth: ________/___________/____________

Service District: __________________________________

Related Service: __________________________________

Recommendation on IEP:

_________	__________	__________	____________
F requency	Duration	Group Size	Language

Location where services are provided (Home, School or Place of Business):_______________________________________

Comments:

Section 2: Provider Information

Provider's Name: __________________________________

Address: _______________________________________

_______________________________________

Telephone #: ( ) ___ ___ ___ - ___ ___ ___ ___

Social Security #: ___ ___ ___-___ ___-___ ___ ___ ___

(Required)

Section 3: Agency Information

Agency Name: __________________________________

Address: _______________________________________

_______________________________________

Telephone #: ( ) ___ ___ ___ - ___ ___ ___ ___

Federal Tax ID #: ___ ___ ___-___ ___-___ ___ ___ ___

(Required)

Section 4: Service Provision


DATE	FREQUENCY	START TIME	END TIME	GROUP	DATE	FREQUENCY	START TIME	END TIME	GROUP
				SIZE					SIZE

1					17

2					18

3					19

4					20

5					21

6					22

7					23

8					24

9					25

10					26

11					27

12					28

13					29

14					30

15					31

16

Total # of Sessions: ____________ Rate: ___________Total Amount Due: _________________________

Section 5:Provider Certification for provision of Services

I hereby certify that I have provided related services on the dates and for the duration indicated herein. I understand that when completed and filed, this form becomes a record of the Board of Education and that any material misrepresentation may subject me to criminal, civil and/or administrative action.

Parent/Principal/Guardian Certification

By my signature I acknowledge that I have reviewed this Related

Service billing form and that, to the best of my knowledge, these

sessions were provided as indicated.

________________________________________________		_____________________________________________________
Signature of Provider	Date	Signature of Parent/Guardian/Principal	Date

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Rsa 7A Form – Fill Out and Use This PDF

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