Click on the following to download:

• EI-1a: H-KISS Referral Form
• EI-1b: Request for H-KISS Identification Number
• EI-2a: Consent for Method of Sharing Information
• EI-2b: Consent for Multidisciplinary Evaluation (MDE)
• EI-2b: Consent for Multidisciplinary Evaluation (MDE) Instructions
• EI-2c: Consent for Release of Billing Information
• EI-2c: Consent for Release of Billing Information Instructions
• EI-2c: Consent for Release of Billing Information Sample
• EI-2d: Authorization for Use or Disclosure of Protected Health Information
• EI-2d-NBHS: Authorization for Use or Disclosure of Protected Health Information
• EI-2e: Consent for Evaluation/Assessment
• EI-3a: IDEA Part C Procedural Safeguard Requirements (Insert for Family Rights)
• EI-3b: Notice of Confidentiality and Access to Records (FERPA Notice)
• EI-3c: Written Prior Notice
• EI-3c: Written Prior Notice Instructions
• EI-4a: IFSP Meeting Notification
• EI-4b: IFSP Form
• EI-4b: IFSP Form Instructions
• EI-6a: AFS
• EI-6a: AFS Instructions
• EI-6b: FFS - AFS Provider Service/Attendance Log
• EI-6c: Provider Quarterly Report
• EI-7a: MDE Report
• EI-7a: MDE Report Instructions
• EI-7b: CDA Report
• EI-7b: CDA Report Instructions
• EI-8a: Part C Transition Conference Meeting Notification
• EI-8b: Part C Transition Notice to DOE
• EI-8b: Part C Transition Notice to DOE Instructions
• EI-10a: Concern Log
• EI-10b: Mediation
• EI-10b: Mediation Procedures
• EI-10c: Formal Complaint
• EI-10c: Formal Complaint Procedures
• EARLY INTERVENTION FORMS LIST

 

(home)