Early Childhood Intervention (ECI) Referral Form

Early Childhood Intervention (ECI) Referral Form

Easterseals Rehabilitation Center
Date

MonthDayYear
Date
My child has been discharged from a NICU within the past month.
Child's Information:
Child's Name

First NameLast Name
Child's Birth Date (ECI is available for children birth up to 36 months old)

MonthDayYear
Child's Gender
Primary Home Language
Ethnicity
Insurance Coverage
Insurance Info (Medicaid, CHIP, Tricare)
Insurance Info Private Insurance
Parent/Guardian Information:
Parent/Guardian #1:

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child's Primary Address
Referral Information:
If the child has a medical diagnosis, please list.
Certification & Consent
I certify the above information is true and accurate to the best of my knowledge.

The Easterseals Rehabilitation Center’s Early Childhood Intervention Program will bill my insurance carrier or any other appropriate third party payer (Example: Medicaid or CHIP). All insurance billings may become part of the aggregate cap of the insured (please check with individual plan for details).
Consent:

I hereby voluntarily give consent for the Easterseals ECI Program to bill my insurance company for the services provided to my child and our family by the Easterseals ECI Team. I further consent for Easterseals ECI program to provide to/receive from the insurance company listed above from the following methods: written, meetings, telephone, computerized data, email, and/or fax. Information will be limited to: Evaluation reports, progress notes, physician's prescription for services, current IFSP, and/or ongoing communication to facilitate the billing process. I understand my consent is voluntary and may be withdrawn at any time. My consent is good for a period of one (1) year unless revoked sooner.
Parent/Guardian Signature:

For Office Use Only:

Case #
TKIDS Case ID #
Initial Date Referral Received
Referral Completion Date
Referral Completed By
Initial Service Coordinator
Date Assigned
IFSP Due

Type of Referral:

New Referral Re-Referral Transfer

Referral Faxed To:

Date:

Should be Empty:

Early Childhood Intervention (ECI) Referral Form

Child's Information:

Parent/Guardian Information:

Certification & Consent