Forms
Authorizations/Approvals
- Prior Approval Request Form SF 51311 (fill-in)
- Final AT Policy and Form SF 50881
- Request for Authorization for Audiology Services SF51930
Data Entry
Data Entry Information request SF53507 (R/2-09) BCD 0220 PDF
Eligibility Determination
- Physician's Health Summary SF51929
- First Steps Part C Eligibility Determination Statement SF 50054 (R4/5-08) BCD 0076
- Documentation of Team Discussion, SF 51928 (R/10-06) BCD 0118
Family Information Update
- Family Information Update SF 51358 PDF
Family Interviews
- Family Interview SF 51313
- Family Interview, Spanish version
- Exit Summary SF 51310
- Exit Summary, Spanish version
Intake
- CSHCS Enrollment Checklist SF48134
- CSHCS Combined Enrollment Form and Instructions can be found at www.in.gov/fssa/files/app3.pdf
Income and Insurance
- Hoosier Healthwise Enrollment Checklist
- Private Medical Insurance Consent SF51308
- Private Medical Insurance Supplement SF51309
- Cost Participation Expenses Worksheet, SF 51359
- Cost Participation Co-Payment Form, SF 51361
- Family Information Update SF 51358
IFSP (Initial or Annual)
- Request for Change to IFSP Services w/ ED Team Response
- IFSP Form SF 46514
- IFSP, Spanish version
- Annual IFSP Checklist SF 51919
- Changes to the IFSP SF 51841
- Documentation of Team Discussion SF 51928
- Reason for Delay of IFSP, revised SF 51312
- Outcome Review SF 51838
- Request for Authorization/Meeting Minutes SF51839
Six (6) Month IFSP Review Packet
- 6 Month (or other planned) IFSP Review Cover Sheet SF 51840
- Outcome Review SF 51838
- Request for Authorization/Meeting Minutes SF 51839
Changes to the IFSP Packet
- Service Change to the IFSP Checklist SF 51921
- Documentation of Team Discussion SF 51928
- Changes to the IFSP SF 51841
On-going Service
- Face to Face Summary Sheet (sample)
- Progress Reports - 1outcome (form)
- Progress Reports - 2outcome (form)
- Progress Reports - 3outcome (form)
- Progress Reports - 4outcome (form)
- Quarterly Contact Checklist (State Form 53975 (6-09) / BCD 0808)
- Third Quarter Checklist (State Form 53976 (6-09) / BCD 0810)
- Intial Contact Checklist (State Form 53977 (6-09) / BCD 0807)
- Service Coordinator Checklist (State Form 53978 (6-09) / BCD 0809)
Referral
- Referral Form (sample)
Releases
- Documentation of Receipt of Rights/Consent to Proceed/Permission to Access SF 51842
- Authorization to Release and Share Medical Information page 1 SF 49006
- Authorization to Release and Share Medical Information page 2 SF 49006
- General Reciprocal Consent to Release and Share Information SF51675
- Electronic Database Release (CRO 1) page 1 SF 49006
- Electronic Database Release (CRO 1) page 2 SF 49006
- Provider Reciprocal Consent to Release and Share Information SF 47960
Termination
- Ongoing Record Termination SF 52001
Transfer to another County
Transition Forms
- Transition Plan Instructions
- First Steps Transition meeting Minutes SF 51674 R3/3-07
- Individualized Family Transition Plan SF 51672 R3/3-07
- Family Information Update SF51358 (R3/3-07)/BCD 0094
- Request for Authorization for Transition Meeting / Transition Checklist SF51670(R3/3-07) BCD 0103
- Transition Meeting Notification SF51671(R3/3-07) BCD 0104
- First Steps 30 Month Notice to Local Educational Agency (LEA) SF51673(R3/3-07) BCD 0106
