Get Ecsii

The Ecsii form is a critical document designed for early childhood service intensity evaluation. Filling out the Ecsii online can be straightforward if you follow these step-by-step instructions, ensuring accurate and efficient submission.

Follow the steps to complete the Ecsii form online.

1. Click ‘Get Form’ button to obtain the Ecsii form and open it in the online editor.
2. In Box 1, enter the last name of the client in uppercase letters, ensuring it is clear and legible.
3. In Box 2, input the first name of the client, also in uppercase letters, with clarity in the letters U, V, I, L, D, and O.
4. Box 3 is for the client's middle initial; enter this in uppercase letters as well.
5. In Box 4, fill in the client's date of birth using leading zeros if needed; ensure the date format is logical.
6. For Box 5, indicate the child's gender by entering 'F' for female or 'M' for male.
7. In Box 6, if applicable, add the OHP member's Medicaid Recipient Identification Number; this is necessary for capitated clients.
8. For Box 7, enter the date of referral for determination using leading zeros; ensure this date is logical.
9. In Box 8, select and enter the appropriate referral source code from the provided list.
10. Box 9 requires you to input the date of determination using leading zeros.
11. Enter the appropriate CMHP ID in Box 10 if the client does not have a Prime Number.
12. For Box 11, enter the MHO Provider Number if applicable or input '000000' for Fee-For-Service clients.
13. For Boxes 12 to 20, indicate scores for the respective ECSII domains, using numbers from 1 to 5.
14. In Box 21, provide the total ECSII score, which is the sum of the previous domain scores.
15. In Box 22, state the preliminary service intensity level based on the total score.
16. In Box 23, indicate if the child is determined ISA with a 'Y' for yes or 'N' for no.
17. For Box 24, enter the recommended service intensity level from 0 to 5.
18. In Box 25, specify the child's placement at the date of determination with the appropriate letter code.
19. For Box 26, enter the logical end date of determination.
20. In Box 27, provide the provider case number for internal reference.
21. Finally, in Box 28, add any necessary provider comments.
22. Once all sections are complete, save your changes, and you can download, print, or share the form as needed.

Complete your Ecsii document online to ensure timely and accurate service evaluation.