Individual Price Authorization



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Refreshed: February 11, 2016

EXECUTIVE OFFICE FOR ADMINISTRATION AND FINANCE

OPERATIONAL SERVICES DIVISION

INDIVIDUAL PRICE AUTHORIZATION


INDIVIDUAL PRICE REQUEST

This Individual Price Request incorporates by reference the pricing approval by the Operational Services Division (OSD) for hourly costs of up to $20. Individual prices are governed by the Operational Services Division Regulation 808 CMR 1.06(7)(a). An “Individual Price” is required for the payment of additional, unique or specialized services for a student that are required by an approved or amended Individual Education Plan (IEP) or Individual Services Plan (ISP) which are not reimbursed in the program’s established price.


If the hourly cost for the service does not exceed $20, send the completed form to:

Department of Elementary and Secondary Education

School Finance and District Support

75 Pleasant St.

Malden, MA 02148
If the hourly cost for the service exceeds $20, send the completed form to:

Operational Services Division

Special Education Pricing

One Ashburton Place, Rm. 1017

Boston, MA 02108
The Individual Price Request may be submitted by a Local Education Authority or other Purchasing Agency responsible for payment for the requested services. It should be sent within 15 calendar days of the execution of the IEP, ISP or amendment. Please enter responsible agency identifying information in item 2 and sign the request form. If the Individual Price Request has been authorized by an Executive Department, attach the authorization to the tuition price letter from OSD (for MMARS documentation).

Please complete all spaces provided for OSD approval, including contact information and if needed any attachments.



Please do not include the student’s name on the request form. Please use the student’s initials and SASID.


  1. INITIALS AND SASID FOR STUDENT REQUIRING SERVICES: INIT.____ SASID_________

2. LOCAL EDUCATION AUTHORITY OR PURCHASING AGENCY:

Name: ____________________________ Telephone No.: ____________________________

Contact: ___________________________ Email: ____________________________

Address ________________________________________________________

3. PRIVATE SCHOOL ATTENDED BY STUDENT:

DESE Program Code: ____

Name: ____________________________ Telephone No.: ____________________________

Contact: ____________________________ Email: ____________________________

4. DATES OF AUTHORIZED INDIVIDUAL SERVICES:

Submit one form for each fiscal year if the IEP dates cross fiscal years. Dates of service must be between 7/1 and 6/30.

From: _________ To:________________

5 REQUESTED SERVICE:

Submit one form for each service.

___ One-to-one aide with a price of up to $20 per hour

___ One-to-one aide with a price of over $20 per hour

___ Other service (specify) _____________________



If the price is above $25 per hour, this form, along with a description of the service and justification for the hourly cost, must be submitted to the Operational Services Division. No justification is needed for occupational, physical or speech therapy, counseling or nursing.

6 AUTHORIZED PRICE:

Hourly cost (including taxes & fringe benefits, if any): $____________________



Total cost: $____________________

I, an authorized representative of the above named Agency, certify that the information contained herein, including any information attached hereto is correct and in accordance with the student’s IEP.
________________________________________________________________________

Name and Title Signature/Date


Document Sensitivity level: Low when form is blank; High when form is filled in.



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