Form DS 5862 Parental Verification for Receipt of Behavioral Services - California

Form ds5862 or the "Parental Verification For Receipt Of Behavioral Services" is a form issued by the California Department of Developmental Services.

Download a fillable PDF version of the Form ds5862 down below or find it on the California Department of Developmental Services Forms website.

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State of California -Health and Human Services Agency
Department of Developmental Services
PARENTAL VERIFICATION FOR RECEIPT OF BEHAVIORAL SERVICES
DS 5862 (6/2011)
Page 1 of 2
1. Consumer Name: ___________________________________________
UCI # : __________________________
(First)
(Last)
2. Vendor Name: _____________________________________________________________________________________
3. Vendor #: ________________________
4. Vendor Phone # _ ______ _________________
5. For Services Provided: Month _______________
Year ________
Name & Credential of
Signature of
Description of Service
Service
Start
End
Date
Location of Service
Person
Parent or
Provided
Code
Time
Time
Providing Services
Legal Guardian
Reset
Save As
Print
State of California -Health and Human Services Agency
Department of Developmental Services
PARENTAL VERIFICATION FOR RECEIPT OF BEHAVIORAL SERVICES
DS 5862 (6/2011)
Page 1 of 2
1. Consumer Name: ___________________________________________
UCI # : __________________________
(First)
(Last)
2. Vendor Name: _____________________________________________________________________________________
3. Vendor #: ________________________
4. Vendor Phone # _ ______ _________________
5. For Services Provided: Month _______________
Year ________
Name & Credential of
Signature of
Description of Service
Service
Start
End
Date
Location of Service
Person
Parent or
Provided
Code
Time
Time
Providing Services
Legal Guardian
State of California--Health and Human Services Agency
Department of Developmental Services
PARENTAL VERIFICATION FOR RECEIPT OF BEHAVIORAL SERVICES
DS 5862 (6/2011)
Page 2 of 2
Instructions to the Vendor: Section
4686.31
of the Welfare and Institutions Code requires any vendor who provides Behavioral Services as
specified in Title 17 of the California Code of Regulations* to submit a completed verification form to the regional center for services provided to
consumers under the age of 18 years who reside in the family home. The vendor must submit the completed verifications to the regional center
with the invoices for the services provided. If the parents or legally appointed guardians of a minor consumer do not submit a verification of
services to the vendor, the vendor shall contact the regional center. Failure of the parents or legally appointed guardians of a minor consumer
to submit a verification of services to the vendor shall not be a basis for terminating or changing behavioral services to the minor consumer.
*This applies to the following Service Codes: 612-Behavior Analyst, 613-Associate Behavior Analyst, 615-Behavior Management
Assistant, 616-Behavior Technician-Paraprofessional, 620-Behavior Management Consultant, 625-Counseling Services, 680-Tutor,
017-Crisis Team-Evaluation and Behavioral Intervention Training, 025-Tutor Services – Group, 048-Client/Parent Support Behavior
Intervention Training, and 077-Parent-Coordinated Home Based Behavior Intervention Program for Autistic Children.
Instructions to the Parents or Legally Appointed Guardians: Please sign, date, and submit this form to your vendor within 30 days from
the time the services were provided. If you are unable to sign the form, please contact your regional center service coordinator/case manager
as soon as possible.
If you have any questions, please feel free to contact your regional center service coordinator/case manager.
I verify that the Behavioral Services provided to the consumer listed on this form were provided at the location, dates, and times as shown and are true, correct, and
complete.
______________________________________
Name of Parent/Legally Appointed Guardian
___________________________________________________
_______________________
Parent or Legally Appointed Guardian Signature
Date

Download Form DS 5862 Parental Verification for Receipt of Behavioral Services - California

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