Get Pa Early Intervention Intake Fax Form - Erie County 2016-2025

The PA Early Intervention Intake Fax Form for Erie County is an essential document utilized to initiate early intervention services for children. Completing this form accurately and thoroughly is crucial in ensuring that your child receives appropriate support from the outset.

Follow the steps to complete the form online efficiently.

1. Press the ‘Get Form’ button to obtain the PA Early Intervention Intake Fax Form and open it in your editor.
2. Fill in the date and indicate whether this is a new intake or a re-admit for the child.
3. Provide the name and birth last name of the child, along with their date of birth (DOB), age, and Social Security Number (SSN). Make sure to select the appropriate race, primary language, and living situation from the options provided.
4. Complete the demographic information for the parent or guardian, including their name, phone numbers (home and office), and emergency contact details.
5. Fill out the insurance information section, indicating if the child has insurance or is under Medical Assistance. Include necessary details such as recipient ID, policy holder name, and policy ID.
6. In the referral details section, specify the referral source and provide their relationship to the child. Fill in their address and phone number. Ensure you indicate whether the parent or guardian has been informed about the referral.
7. Detail the referral reasons by selecting from the provided options and offer additional comments if necessary.
8. In the diagnosis details section, indicate any relevant diagnoses and check yes or no regarding any screenings that have been conducted.
9. Lastly, check the availability of documentation for screenings and disclose any community agency involvement along with disposition details.
10. Once all sections are completed, save the changes to the form, and you may download, print, or share it as needed.

Complete your documents online today to ensure timely access to early intervention services.