Form 814e - Early Intervention Referral Form - Mississippi State Department Of Health
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3Early Intervention Referral Form 814E
Instructions
PURPOSE
The purpose of the Early Intervention Referral Form is to notify the First Steps Early Intervention
Program of potentially eligible infants/toddlers who might have a developmental delay or a disability that
is likely to result in a developmental delay if intervention services are not provided.
INSTRUCTIONS
1. The form should be completed for infants/toddlers birth to three years of age who have or are
suspected of having a: disability, developmental delay, or diagnosed conditions that is likely to result
in developmental delay(s).
2. Anyone (i.e., parents, health care providers, childcare providers) can make a referral to Early
Intervention.
•
Healthcare providers who serve infants/toddlers from birth to age three are required by state and
federal regulations to make referrals within seven days of determining that an infant/toddler is
possibly in need of early intervention services.
3. Referrals should be made/sent directly to the Early Intervention Central Office by:
a. Fax: (601)-576-7540 or
b. Mail: Mississippi State Department of Health
Early Intervention
P.O. Box 1700
Jackson, MS 39215-1700 or
c. Phone: 1-800-451-3903 or (601) 576-7427
Please print the requested information in each blank (*indicates required information)
DEMOGRAPHIC DATA
Child’s Name*: Enter the Child’s first, middle and last name.
Sex*: Check if the child is a male or female.
Date of Birth*: Enter the child’s date of birth (mm/dd/yyyy).
Medicaid#: Enter the child’s Medicaid# (if applicable).
Social Security#: Enter the child’s Social Security#.
Ethnicity*: Check one ethnicity (Hispanic/Latino or Non-Hispanic/Latino).
Primary Language*: Indicate the primary language for the child (English, Spanish, or
Other (specify)).
Race*: Check child race based on family’s self-report. More than one race may be chosen from the list
(White, Black/African American, Asian, Pacific Islander and/or American Indian/Alaska Native).
Parent(s)/Guardian(s)*: Enter the child’s parent(s)/guardian(s) name.
Address*: Enter the child’s physical address (no PO Box address).
City*: Enter the city that the child resides in.
Zip code*: Enter the zip code for the address that was provided.
County*: Enter the county that the child resides in.
Phone #’s*: Enter the phone numbers (Home, cell or other) of the parent(s)/guardian of the child.
Email: Enter the email address of the parent(s)/guardian(s) of the child.
Insurance Carrier (1)*: Enter the primary insurance company name that insures the child.
Insurance Carrier (2): Enter a secondary insurance company’s name that insures the child.
Insurance Identification # (1): Enter the child’s primary insurance identification #.
Mississippi State Department of Health
Revised 07/01/2014
Form #814E
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Parent category: Medical