Billing form 2026

1. Click ‘Get Form’ to open the Independent Providers of Related Service Billing Form in the editor.
2. Begin by filling out Section 1: Student Information. Enter the student's name, NYC ID #, date of birth, and related service details such as service district, IEP recommendation, hourly rate, frequency, duration, group size, language, and location of services provided (home, school, or place of business).
3. Proceed to Section 2: Provider Information. Input your social security number, name, address, email address, and telephone number.
4. In Section 3: Agency Information, provide the federal tax ID number along with the agency's name, address, email address, and telephone number.
5. Move on to Section 4: Service Provision. Fill in the date of service provision, frequency of sessions, total number of sessions provided, start time, end time, group size and calculate the total amount due.
6. Finally, complete Section 5: Certification by signing and dating the form to certify that services were provided as indicated. Ensure that a parent/guardian/principal also reviews and signs if necessary.

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