Form HFS652 "Illinois Early Intervention Program Referral Fax Back Form" - Illinois

What Is Form HFS652?

This is a legal form that was released by the Illinois Department of Healthcare and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Illinois Department of Healthcare and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HFS652 by clicking the link below or browse more documents and templates provided by the Illinois Department of Healthcare and Family Services.

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Download Form HFS652 "Illinois Early Intervention Program Referral Fax Back Form" - Illinois

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State of Illinois
Department of Healthcare and Family Services
Illinois Early Intervention Program
Referral Fax Back Form
PART 1 of 2
Complete Part 1 upon contacting the family, or when a family cannot be contacted in a timely manner. If the
parent/guardian consented to the release of information in Section 6 of the Standardized Illinois Early
Intervention Referral Form to the health care provider listed in Section 4 and/or the referral source listed in
Section 3, send Part 1 of the Referral Fax Back Form to the health care provider and/or the referral source for
which consent was provided. If the parent/guardian did not consent to the release of information to either the
healthcare provider or the referral source, then information cannot be sent to the entity for which consent
was not given.
Date:
Child's Name:
Date of Birth:
Parent/Guardian Name:
Date Referral Received:
This child was referred to our Child and Family Connections office. The following is the status of that referral:
The family was contacted on (date):
A Service Coordinator has been assigned to the family:
Name:
CFC# / Location:
/
Phone Number:
Fax Number:
E-Mail:
Repeated attempts have been made to contact this family - we were unable to establish contact.
Date final contact attempt made:
Please let us know if the family is still interested in having an evaluation for their child.
The family has been contacted and requests that you contact them directly for results.
Date request made by family:
The family has declined services at this time.
Date service declined:
Additional comments:
HFS 652 (R-3-18)
Page 1 of 2
State of Illinois
Department of Healthcare and Family Services
Illinois Early Intervention Program
Referral Fax Back Form
PART 1 of 2
Complete Part 1 upon contacting the family, or when a family cannot be contacted in a timely manner. If the
parent/guardian consented to the release of information in Section 6 of the Standardized Illinois Early
Intervention Referral Form to the health care provider listed in Section 4 and/or the referral source listed in
Section 3, send Part 1 of the Referral Fax Back Form to the health care provider and/or the referral source for
which consent was provided. If the parent/guardian did not consent to the release of information to either the
healthcare provider or the referral source, then information cannot be sent to the entity for which consent
was not given.
Date:
Child's Name:
Date of Birth:
Parent/Guardian Name:
Date Referral Received:
This child was referred to our Child and Family Connections office. The following is the status of that referral:
The family was contacted on (date):
A Service Coordinator has been assigned to the family:
Name:
CFC# / Location:
/
Phone Number:
Fax Number:
E-Mail:
Repeated attempts have been made to contact this family - we were unable to establish contact.
Date final contact attempt made:
Please let us know if the family is still interested in having an evaluation for their child.
The family has been contacted and requests that you contact them directly for results.
Date request made by family:
The family has declined services at this time.
Date service declined:
Additional comments:
HFS 652 (R-3-18)
Page 1 of 2
PART 2 of 2
To be completed after eligibility is determined and the Individual Family Service Plan (IFSP) is completed to
inform the health care provider and/or referral source about Early Intervention eligibility, other referrals
provided and other Early Intervention service(s) recommended, if eligible.
Note: if the parent/guardian consented to the release of information in Section 6 of the Standardized Illinois
Early Intervention Referral Form to the health care provider listed in Section 4 and/or the referral source
listed in Section 3, send Part 2 of the Referral Fax Back form to the health care provider and/or the referral
source for which consent was provided. If the parent/guardian did not consent to the release of information
to either the health care provider or the referral source, then information cannot be sent to the entity for
which consent was not given.
Date:
Child's Name:
Date of Birth:
Parent/Guardian Name:
The family has been contacted and the following has occurred:
1.
The child has been evaluated and found to be not eligible for services at this time (Skip to #4)
The child has been evaluated and found to be eligible for services based on the following:
30% or greater developmental delay
Qualifying Diagnosis of:
Other:
The child and family have been recommended to receive the following Early Intervention services:
2.
Developmental Therapy
Occupational Therapy
Physical Therapy
Speech Therapy
Social Work/Counseling
Other:
Notes:
An IFSP was/will be developed for the child and family. The IFSP Summary Report will be released to the
3.
health care provider identified in Section 6, Authorization to Release Information, in the Standardized Illinois
Early Intervention Referral Form (a full copy of the plan may be obtained through the contact listed in Part 1).
4.
The child and family received referrals to the following non-EI services:
The evaluation/assessment and service planning process have not been completed because:
5.
Additional comments:
HFS 652 (R-3-18)
Page 2 of 2
Page of 2