Get Oregon Abcd Ei/ecse Referral Form - Oregon Health & Science ... - Ohsu

Filling out the Oregon ABCD EI/ECSE Referral Form is a crucial step in accessing early intervention services for children. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the Oregon ABCD EI/ECSE Referral Form online.

1. Press the ‘Get Form’ button to retrieve the form and access it in your document editor.
2. Begin with the child/parent contact information section. Fill in the child's name, date of birth, and the parent or guardian’s name and relationship to the child. Provide the complete address, including city, state, and zip code. Ensure the primary and secondary phone numbers and email address are included.
3. Indicate the primary language and whether an interpreter is needed by selecting 'Yes' or 'No'.
4. Specify the type of insurance your child has, if any, by checking the appropriate boxes. If there is no insurance, specify that as well.
5. Complete the section for the child's doctor’s name, location, and phone number if known.
6. In the parent consent for release of information section, the parent or guardian must print their name, sign, and date the consent form. This section grants permission for sharing pertinent information with EI/ECSE services.
7. Move on to the office use only section for future reference regarding the referral process.
8. For the reason for referral to EI/ECSE services, complete the applicable areas. Attach completed screening tools where referenced, and mark any areas of concern.
9. Provide the provider information for the referral. Enter your name and title as the referring provider, along with the office phone and fax number.
10. In the section requesting referral results, indicate the desired information to be included in the child’s health records.
11. Once all sections are completed, review the entire form for accuracy. Make sure all necessary signatures are obtained before submission.
12. Save any changes made to the form. You can download, print, or share the completed form as necessary.

Complete your forms online to ensure timely access to early intervention services.