Early Intervention/early Childhood Special Education (Ei/ecse) Referral Form For Providers* Birth To Age 5 Form (Page 4 of 4) in pdf

Early Intervention/Early Childhood Special Education (EI/ECSE) Referral Form for Providers* Birth to Age 5

CONSENT FOR USE OR DISCLOSURE OF HEALTH INFORMATION BETWEEN

HEALTHCARE PROVIDERS and EARLY INTERVENTION

Information for Parents

This consent for release of information authorizes the disclosure and/or use of your child’s health

information from your child’s health care provider to the Early Intervention/Early Childhood Special

Education (EI/ECSE) program. This consent form also authorizes the disclosure of developmental and

educational information from the Early Intervention/Early Childhood Special Education program to your

child’s health care provider.

Why is this consent form important?

Your child's health care provider sees your child at well-child screening visits and for medical treatment.

Sometimes your child’s health care provider may see the need for more information, like evaluation or

follow up by other specialists, to identify your child’s special health care needs. The Early

Intervention/Early Childhood Special Education (EI/ECSE) program can be a resource to help identify

your child’s needs. The primary goal of this consent form is to allow communication between your child’s

health care provider and EI/ECSE programs so these providers can work together to help your child.

Why am I asked to sign a consent on this form?

The consent allows your child’s health care provider to share information about your child with EI/ECSE,

and allows EI/ECSE to share information about your child with your health care provider. Your consent

for the release of information allows your child’s health care provider and EI/ECSE communicate with

one another to ensure your child gets the care your child needs. However, as your child’s parent or legal

guardian you may refuse to give consent to this release of information.

How will this consent be used?

This consent form will follow your child as he/she is screened and/or evaluated at EI/ECSE. The

information generated by this release will become a part of your child’s medical and educational records.

Information will be shared with only individuals working at or with EI/ECSE or the office of your child’s

health care provider for the purpose of providing safe, appropriate and least restrictive educational

settings and services and for coordinating appropriate health care.

How long is the consent good for?

This consent is effective for a period of one year from the date of your signature on the release.

What are my rights?

You have the following rights with respect to this consent:

You may revoke this consent at anytime.

You have the right to receive a copy of the Authorization

Form Rev. 06/20/2012

Early Intervention/early Childhood Special Education (Ei/ecse) Referral Form For Providers* Birth To Age 5 Form Page 4