Form HFS650 "Standardized Illinois Early Intervention Referral Form" - Illinois

What Is Form HFS650?

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 HFS650 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 HFS650 "Standardized Illinois Early Intervention Referral Form" - Illinois

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State of Illinois
Department of Healthcare and Family Services
Standardized Illinois Early Intervention Referral Form
Please complete Sections 1 through 6 of this form to refer a child to Early Intervention (EI) for eligibility determination.
Section 1. Child Contact Information
If the child is known by
Child Name:
another name enter it here:
Gender: Male
Date of Birth:
Child Age:
Race:
Female
Address:
City:
State
Zip Code
County
Type of Insurance Coverage:
Medicaid
Private Insurance
None
Parent/Guardian Name:
Relationship to Child:
Primary Language:
Home Phone
Other Phone
Alternate or Emergency Contact Person:
Phone Number
Section 2. Reason(s) for Referral
Reason(s) for referral to EI (Please check all that apply):
Date referral made:
Identified physical or mental condition
Medical Diagnoses
(List of
or type URL
http://www.dhs.state.il.us/page.aspx?item=96962
).
If yes, please describe:
Suspected developmental delay based on objective screening
(please name tool(s)):
Check area[s]
Motor/Physical
Social/Emotional
Cognitive
Speech
Behavior
of concern:
Vision/Hearing
Language/Communication
Adaptive/Self-help Skills
Comments:
At risk conditions (e.g., diagnosed caregiver condition, other risk factors to child) (List of
At Risk Conditions
or type
URL
http://www.dhs.state.il.us/page.aspx?item=96963), please describe:
Other, (Please describe):
Family is aware of reason for referral
Section 3. Referral Source Contact Information
If the child's Health Care Provider is making the referral, skip Section 3 and complete Section 4. If an Early Childhood
Program is making the referral, check here. NOTE: Any agency may use this referral form.
Name of Agency Making Referral:
Address:
City
State
Zip Code
Office Phone
Office Fax
E-mail
Contact Person at Referral Site:
Section 4. Health Care Provider Contact Information
Agencies listed in Sec. 3, please complete Sec. 4 (with parental consent) to assure child's Health Care Provider is informed of
referral.
Name of Child's Health Care Provider:
Street Address:
City
State
Zip Code
HFS 650 (R-3-18)
Page 1 of 2
State of Illinois
Department of Healthcare and Family Services
Standardized Illinois Early Intervention Referral Form
Please complete Sections 1 through 6 of this form to refer a child to Early Intervention (EI) for eligibility determination.
Section 1. Child Contact Information
If the child is known by
Child Name:
another name enter it here:
Gender: Male
Date of Birth:
Child Age:
Race:
Female
Address:
City:
State
Zip Code
County
Type of Insurance Coverage:
Medicaid
Private Insurance
None
Parent/Guardian Name:
Relationship to Child:
Primary Language:
Home Phone
Other Phone
Alternate or Emergency Contact Person:
Phone Number
Section 2. Reason(s) for Referral
Reason(s) for referral to EI (Please check all that apply):
Date referral made:
Identified physical or mental condition
Medical Diagnoses
(List of
or type URL
http://www.dhs.state.il.us/page.aspx?item=96962
).
If yes, please describe:
Suspected developmental delay based on objective screening
(please name tool(s)):
Check area[s]
Motor/Physical
Social/Emotional
Cognitive
Speech
Behavior
of concern:
Vision/Hearing
Language/Communication
Adaptive/Self-help Skills
Comments:
At risk conditions (e.g., diagnosed caregiver condition, other risk factors to child) (List of
At Risk Conditions
or type
URL
http://www.dhs.state.il.us/page.aspx?item=96963), please describe:
Other, (Please describe):
Family is aware of reason for referral
Section 3. Referral Source Contact Information
If the child's Health Care Provider is making the referral, skip Section 3 and complete Section 4. If an Early Childhood
Program is making the referral, check here. NOTE: Any agency may use this referral form.
Name of Agency Making Referral:
Address:
City
State
Zip Code
Office Phone
Office Fax
E-mail
Contact Person at Referral Site:
Section 4. Health Care Provider Contact Information
Agencies listed in Sec. 3, please complete Sec. 4 (with parental consent) to assure child's Health Care Provider is informed of
referral.
Name of Child's Health Care Provider:
Street Address:
City
State
Zip Code
HFS 650 (R-3-18)
Page 1 of 2
Office Phone
Office Fax
Contact Person at
E-mail
Health Care Provider Office:
Section 5. Early Intervention CFC Office Referral Location
FAX form to the CFC where the child is being referred: CFC #:
If CFC is unknown, use child's county/ZIP code, locate CFC office using the DHS Office Locator at:
http://www.dhs.state.il.us/page.aspx?module=12
Section 6. Authorization to Release Information
1. Consent for Referral to Early Intervention and for Release of Health Information to Early Intervention Program
The purpose of this disclosure is to refer (print child's name)
to the Illinois Early Intervention program.
I, (print name of parent or guardian),
give my permission for my child's health care provider, (listed in Section 4 above) to share pertinent information about my child,
(print child's name)
regarding suspected developmental delay or related medical conditions with the Early Intervention program. I understand that I
may withdraw this consent by written request to my child's health care provider, except to the extent it has already been acted
upon.
2. Consent to Release Early Intervention Reports and Results to Healthcare Provider and/or Other Referring Agency.
Your consent allows the Early Intervention program to share reports and results, as listed in the EI Fax Back Form, with your
child's health care provider listed in Section 4, or the referral entity. The CFC will send the HFS 652 Illinois Early Intervention
Program Referral Fax Back form with the appropriate information:
https://www.illinois.gov/hfs/SiteCollectionDocuments/
hfs652.pdf
3. Consent to Release Early Intervention Eligibility Determination and Service Information to Illinois Department of
Healthcare and Family Services. For children enrolled in All Kids, your consent allows the release of information from
Department of Human Services (DHS) to the Department of Healthcare and Family Services (HFS) about your child, including
name, AllKids recipient identification number, date of birth, and information about your child's referral to and eligibility for Early
Intervention, including services received and other referrals made by Early Intervention. Your consent allows HFS to share
information with your child's health care provider (listed in Section 4 above, if any) and treating doctors within the group, and
managed care organization (MCO), if applicable, for care coordination. Care coordination allows your child's health care provider
to be notified with results of your child's Early Intervention evaluation and/or assessment, eligibility for services and services
received. Your consent allows HFS to use the information for analysis purposes and to measure the quality of the care
coordination process between the health care provider and Early Intervention. Information and reports resulting from data
analysis will not be released with any individually identifying information about your child.
I understand that I may withdraw this consent by written request to Early Intervention, except to the extent it already has been
acted upon. I certify that this Authorization to Release Information has been given freely and voluntarily. Information collected
hereunder may not be re-disclosed unless the person who consented to this disclosure specifically consents to such re-disclosure
and or the re-disclosure is allowed by law. I understand I have a right to inspect and copy the information to be disclosed.
Parent/Legal Guardian Signature*
Date
*Consent is effective for a period of 12 months from the date of your signature on this release.
Section 7. For CFC Office Use Only
Date Referral Received:
Name of person receiving referral:
HFS 650 (R-3-18)
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