Form 814e - Early Intervention Referral Form - Mississippi State Department Of Health Page 2
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3Insurance Identification # (2): Enter the child’s secondary insurance identification #.
Covered Party (1): If applicable check which type the child has (Medicaid, CHIP, MSCAN (United
Health Care or Magnolia Health).
Covered Party (2): If applicable check which type the child has (Medicaid, CHIP, MSCAN (United
Health Care or Magnolia Health).
Primary Health Care Provider*: Enter the primary agency and provider’s name of the child.
Address: Enter the address of the primary health care provider.
City: Enter the city of the primary health care provider.
State: Enter the state of the primary health care provider.
Zip: Enter the zip code of the primary health care provider.
Phone #’s: Enter the primary health care provider’s office and fax number.
Email: Enter the primary health care provider’s email address.
Referral Source: Enter the name of the person who made the referral, what relationship (i.e., mother,
grandparent, nurse) referral source has to the child and the referral source’s phone #.
REASON FOR REFERRAL*
Identify the main reason that the child is being referred to the program. If the child has a known medical
condition (i.e., genetic disorder, sensory impairment, neurological disorder) that will result in a
developmental delay check which primary medical condition the of child. If the child has no medical
condition, but has possible developmental delays (i.e., speech, adaptive) check the suspected
developmental delay box.
FOR EARLY INTERVENTION STAFF USE ONLY
Date Referral Received by EI Program: Enter the date the EI program (Central Office or Local
District) received the referral form.
Date sent to Central Referral Unit: If the referral form was received at the Local District enter the date
that the referral was sent to Central Office.
Who received referral: Enter the name of the EI staff that received the referral form
District Assigned to: Enter the District that the referral form has been assigned to.
Assign SC: Enter the name of the service coordinator that will receive notice of the referral form.
OFFICE MECHANICS
FILING
and
Information from the Early Intervention Referral Form will be entered into the Child Registry by a
Central Office staff and the original referral form will be scanned into the child’s file in the Child
Registry. Once the original referral form is entered and scanned into the registry it will be shredded.
RETENTION PERIOD
The scanned Early Intervention Referral Form shall remain in the child’s Early Intervention Record until
the participating agency is no longer required to maintain or no longer maintains that information under
applicable Federal and State laws.
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Parent category: Medical