Educational Therapies and Services Pre-Approval & Agreement Form

This form must be submitted and approved by the Tennessee Department of Education (the department) before IEA funds can be used to pay for any educational therapy services.

IEA account holders must submit a new form each IEA contract year, for each therapy provider.

  • Educational therapy pre-approvals are only valid until the date the provider's license expires or the end of the current contract year, whichever comes first; the date of expiration will be included in the approval notice from the department.

To use IEA funds to pay for educational therapy for a participating student, the therapy service must be provided by a therapist who meets the licensing requirements set by the State Board of Education and the department (please see Chapter 6 of the IEA Account Holder Handbook for complete details).

Account holders must submit to the department proof of the therapy provider's licensing credentials with this form.

In addition, by signing this document, the IEA account holder is verifying that the provider complies with the IEA rules, procedures, and other requirements set in the IEA Account Holder Handbook regarding the professional liability insurance requirements and criminal background check. 

SBE Rule 0520-01-11-.02(7) requires, at a minimum, a criminal background check for IEA tutoring and therapy providers include:

  1. a check of the Tennessee Sex Offender Registry;
  2. a check of the Tennessee Department of Health’s Abuse Registry, and
  3. a fingerprint-based criminal history records check conducted by the Tennessee Bureau of Investigation (TBI) and forwarded by the TBI to the Federal Bureau of Investigation (FBI).

The department does not endorse any products, providers, services, etc. The department only determines whether the therapy services listed on this form meet the qualifications outlined in the IEA Account Holder Handbook.

Please allow up to 5 business days for the department to process this form.


Tennessee Department of Education
Individualized Education Account (IEA) Program
Andrew Johnson Tower, 10th Floor
710 James Robertson Parkway • Nashville, TN 37243
Tel: (615) 253-3781• Fax: (615) 741-6793

ED5526 RDA 11163

Directions: Please provide the information in the fields below.

Student Name*
Account Holder Name*

ED5526 RDA 11163

Provider Information

Therapist Name*
Business Address*
Does the therapist name and credentials match what is in the Tennessee teacher license system (TNCompass), which you can access by going to: https://tdoe.tncompass.org/Public/Search?*
Does the therapist name and credentials match what is in the Tennessee Department of Health’s license verification system which you can access by going to: https://apps.health.tn.gov/licensure/?*
Does the therapist name and credentials match what is in the Behavior Analyst Certification Board’s website which you can access by going to: https://bacb.com/?*

Description of Educational Therapy

In order to use IEA funds for educational therapies and services, account holders must provide a description of how the therapy is meeting the student's educational needs. “Educational therapies” must be individualized services designed to develop or improve academic performance through instructional and therapeutic techniques, and provided by therapists that meet the requirements set by the State Board of Education and the department. For more information, see Chapter 6 of the IEA Account Holder Handbook.


It is optional, but recommended, to submit a fee schedule for the educational therapist.
No File Chosen
File uploads may not work on some mobile devices.

Sensory & Tactile Manipulatives

Rule 0520-01-11-.02(9)(b): “Educational Therapies” means . . . tactile manipulatives recommended by the licensed therapist for the Participating Student pursuant to guidelines set forth by the Department.

List of Recommended Manipulative(s) Provided by the Therapist*
No File Chosen
File uploads may not work on some mobile devices.
This should be on letterhead and signed by the department-approved therapist.

IEA Account Holder Agreements

By signing your initials, you are acknowledging your agreement to each statement.

Agreement Statement

I certify that the therapy services directly go to improve the education of the student.

I certify that the provider has completed a criminal background check pursuant to the Rules of the State Board of Education Chapter 0520-01-11.

I agree to notify the department if any provider information changes.


I certify that the provider has never been convicted of a felony, including conviction on a plea of guilty, a plea of nolo contendere, or order granting pre-trial diversion.

I understand that it is a conflict of interest and against IEA program rules and procedures for a family member of a participating student, including stepparent or a member of a participating student’s household, to provide services or professional recommendations.

I certify that the therapist holds professional liability insurance.

I certify the information provided in this form, including any supporting documentation, is truthful and accurate. I further understand that any false statements or documentation may result in the student’s account being frozen, the student being removed from the IEA program, closure of the student’s IEA account, and/or forfeiture of all funds remaining in the account. I further understand that if any false statements or documentation is provided, the department may prohibit the student and/or parent/guardian from enrolling in the IEA Program and/ or being an IEA account holder in future.

Use your mouse or finger to draw your signature above
Date*
Cancel
Confirm