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Get Early Intervention Referral Form
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How to fill out the Early Intervention Referral Form online
The Early Intervention Referral Form is a critical document for referring a child to Early Intervention services for eligibility determination. This guide provides step-by-step instructions on how to complete the form online effectively and accurately.
Follow the steps to fill out the Early Intervention Referral Form:
- Click ‘Get Form’ button to obtain the form and open it in the appropriate editor.
- In Section 1, input the child's contact information, including their full name, date of birth, and age. Specify any known alternate names, along with the child's gender, race, address, insurance details, and the contact information for the parent or guardian. Ensure that all fields are filled out carefully for accurate processing.
- In Section 2, indicate the reasons for referral by checking all applicable boxes. Provide details regarding any identified medical conditions or suspected developmental delays, including the specific areas of concern. Add any additional comments that may help clarify the referral.
- If applicable, complete Section 3 by providing the referral source contact information. If the Primary Care Provider made the referral, select the designated box to skip this section.
- In Section 4, enter the Primary Care Provider's contact information, including their name, address, phone number, and email. This information is crucial for coordinating services.
- Fill in Section 5 with the CFC number corresponding to the child's referral location. Use the provided resources to locate the correct CFC office as needed.
- Complete Section 6 by signing the Authorization to Release Information. Ensure that all required names and details are filled in correctly. Be aware that consent is valid for a period of 12 months.
- Review the completed form for accuracy. Once satisfied, users can save changes, download, print, or share the form as appropriate.
Encourage others to complete their Early Intervention Referral Form online today for efficient processing.
Filling out a medical referral form involves similar steps as the Early Intervention Referral Form. Begin by providing the patient's identifying information, including their name, age, and reason for referral. Clearly outline any medical history or specific issues that require attention, as these details are vital for the medical team to plan appropriate care.
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