Provider Notice issued 07/30/14

Standardized Referral Form for Early Intervention

An objective developmental screening using a recognized instrument is a structured evaluation of a child's development (i.e., physical, language, intellectual, social-emotional) and is performed by the primary care provider (PCP) or other trained provider. Children should be referred for a comprehensive evaluation and services as an outcome of the well-child visit or as indicated by the results of an objective developmental screening tool. Please refer to the Handbook for Providers of Healthy Kids Services (pdf) Section HK-203.5 Developmental Screening and Assessment for more information.

Referrals

When a child, three years of age or younger, needs a comprehensive evaluation for suspected developmental delay, a referral to the Department of Human Services’ (DHS) Early Intervention (EI) program, Child and Family Connections (CFC) offices can be made using the “Standardized Illinois Early Intervention Referral Form” Form 650, available on HFS’ Medical Program Forms webpage. Search either alphabetically or by form number. The form can be printed or saved to your computer for use. The form includes a hyperlink to an online tool to look up the CFC office(s) serving your area. A list of CFC offices by the counties they serve is attached to this Notice for reference.

The advantages of using the standardized referral form are:

1. The form secures consent that meets Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA) requirements;

2. The form initiates a process whereby EI CFC office staff send information back to the referring provider about the outcome of the referral; and

3. The referral form is sent from the provider directly to the local EI CFC office thereby removing the burden on the family to contact EI.

Providers are strongly encouraged to use the standardized referral form to ensure transfer of a consistent set of information that is actionable by the EI CFC office staff.

The referral form is paired with a standardized “Illinois Early Intervention Program Referral Fax Back Form” Form 652 (available on the Medical Program Forms webpage) to assure that the referring provider, with proper consent secured using the referral form, receives information about the outcome of the referral. EI CFC staff complete Part 1 of 2 after they contact the family to inform the referring provider about the outcome of the contact. When EI CFC staff cannot reach the family, providers should follow-up with the family to encourage them to contact their local EI office. Part 2 of 2 is completed by EI CFC staff after the child receives an assessment to inform the provider about the outcome.

Currently, these forms are faxed between the provider and the local EI CFC office. In development is an online referral system whereby providers may send referral information electronically to the local EI CFC office. The referring provider will be notified via e-mail that outcome information is available. Information about this developing process will be shared at a later date.

The forms and communication processes were tested through a pilot project conducted by HFS, DHS and the Illinois Chapter, American Academy of Pediatrics (ICAAP). The project was funded by The Commonwealth Fund and administered by the National Academy for State Health Policy.

Providers wishing to receive e-mail notification when new provider information is posted by the Department may register on the HFS Provider Releases and Bulletins E-mail Notification Request webpage.

Theresa A. Eagleson, Administrator

Division of Medical Programs

Child and Family Connections Listing of Illinois

Illinois Department of Human Services- Bureau of Early Intervention Early Intervention

Revised – June 2014