Infant & Toddler Connection Of Virginia Referral Form printable pdf download

Infant & Toddler Connection of Virginia Referral Form

Physicians: Please complete this form for referring a child to early intervention if you prefer to do so in writing. Also

please indicate the feedback that you want to receive from the early intervention program in response to your referral.

Child Contact Information

Child Name: ___________________________________________Date of Birth: _____/_____/_____ Gender M F

Home Address: __________________________________________________City______________________Virginia Zip_______

Parent/Guardian______________________________Relationship to Child: ___________________________________________

Primary Language:_____________ Home Phone:______________Other Phone:___________________________________

Reason for Referral and Referral Information

Developmental Evaluation, which may include evaluations by special instructor and/or physical and/or occupational therapist and/or

speech language pathologist.

Medical Information (Please check all that apply):

Identified condition or diagnosis (e.g., spina bifida, Down syndrome): __________________________________________________

Suspected developmental delay or concern (Please circle areas of concern):

Motor/Physical Cognitive Social/Emotional

Speech/Language Behavior

Vision Hearing Other_____________________

Assessment Method/Tool used to identify delay or concern:___________________________________________________________

Other (Please Describe):_____________________________________________________________________

Feedback Requested by the Referral Source

Status of Initial Family Contact

Services Being Provided to Child/Family

Other:________________________

Developmental Evaluation Results

Child Progress Report/Summary

Referral Source Contact Information

Person Making Referral:________________________________________________ Date of Referral:_______/_______/_______

Address:_________________________________________________________________________________________________

Office Phone_____/_____-_______Office Fax:_____/_____-_______E-mail____________________________________________

Signature:_________________________________________________

Infant & Toddler Connection Information

Program Name: ___________________________________________________________________________________________

Address: ______________________________________________City: ________________________State: ______Zip:________

Telephone Number: ______________________________________Fax Number: _______________________________________

E-mail___________________________________________________________________________________________________

Consent for Release of Protected Health Information

Extent or nature of use/disclosure is limited to: (Check or list all that apply)

History and Physical, including vision and hearing_____ discharge summaries___ evaluation reports ____

IFSP___ Progress notes____ other_____________________________________________________________________

Specified purpose or need for use/disclosure is: Intervention and Coordination of Care

Permission is hereby given to: ______________________________________ (Referral Source Name) to disclose information to:

____________________________________________________________________________, (Local Early Intervention System Name,

Street Address, City, State, Zip Phone/Fax #). I also authorize the recipient to use the information received pursuant to this authorization.

As the person signing this authorization, I acknowledge that I am giving my permission to the above-named person/class of persons to

disclose and use protected health information.

Permission is hereby given to: ______________________________________ (Local Early Intervention System Name) to disclose

information to:__________________________________________________________________, (Referral Source name, title and

organization, Street Address, City, State, Zip Phone/Fax #). I also authorize the recipient to use the information received pursuant to this

authorization. As the person signing this authorization, I acknowledge that I am giving my permission to the above-named person/class of

persons to disclose and use protected health information. I further acknowledge that:

This authorization ___does ___ does not extend to information placed in my record after the date I signed this form.

I acknowledge that I have read and understand the following.

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I may refuse to sign this authorization.

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The referral source and the early intervention system cannot condition the provision of treatment to me on my signing of this authorization.

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The original or a copy of this authorization shall be included with my original records.

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I have the right to revoke this authorization at any time, except to the extent that action has been taken in reliance on it, by delivering the revocation

in writing to the provider who is in possession of my health care records.

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There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipient and, therefore, no longer

protected by the provisions of the HIPAA Privacy Rule.

Signature of Individual (adult) or Legally Authorized Representative___________________________________________________

Relationship____________________________________ Date Signed___________________________________________________

If not previously revoked, this authorization will expire in: ___90 Days ___One Year ___On

(specify date or event)_____________________

The information may be disclosed effective: ____Immediately ___

(specify date)________

3/28/08