20) Forms, Sample Letters, and Reference

Child and Family Connections Statewide Forms

• Assistive Technology Prior Approval Request (pdf)
• Change Of Insurance Notification (pdf)
• Child Find Screening and Data Collection (pdf)
• Consent for Release of Information (pdf)
• Consent for Release of Information for Children with Identified Hearing Loss (pdf)
• Cornerstone Informed Consent Form (pdf)
• Early Intervention to Early Childhood Transition Tracking Form (pdf)
• EI Notice of Privacy Practices (pdf)
• Family Participation Fee Exemption Request (pdf)
• CFC Fax Cover Sheet For Insurance Requests (pdf)
• Fee Credit Request Form (pdf)
• Individualized Family Service Plan Meeting Attendance Waiver for Audiologists (pdf)
• Informed Consent & Documentation of Receipt Of Rights and Notice of Privacy Practices (pdf)
• Insurance Affidavit, Assignment And Release (pdf)
• Insurance Exemption Request (pdf)
• Natural Environments Worksheet (pdf)
• Parent Reimbursement Request (pdf)
• Pre-Billing Insurance Waiver Request (pdf)
• Provisional Provider Authorization Request (pdf)
• Request for Administrative Resolution of Complaint by an Impartial Hearing (pdf)
• Request for Investigation of State Complaint (pdf)
• Request for Mediation (pdf)
• Screening Device for Determining Family Fees And Eligibility for All Kids & DSCC (pdf)
• Waiver of Written Prior Notice (pdf)

Sample Forms Letters

• 30-F04 Ineligible Based on General Eligibility
• 30-F08 Intake Appointment Confirmation
• 30-F14 Initial Contact - Unable to Contact by Phone
• 30-F16 Second Contact - Unable to Contact by Phone
• 30-F20 Discontinuation of One or More Services
• 30-F28 Ineligible Based on Evaluation
• 30-F32 Eligible
• 30-F36 IFSP Meeting

Reference Materials

Early Intervention Service Descriptions, Billing Codes and Rates

Early Intervention Assistive Technology Guidelines and Attachments (pdf)
Attachment A: Assistive Technology Equipment - 10/03

Individualized Family Service Plan (IFSP)
Form Instructions And Non-Cornerstone Service Plan Pages:

• Section 1: Family Considerations (optional)
• Section 3: Functional Outcomes
• Section 7: Implementation and Distribution Authorization
• Section 8: Meeting Participation/Contributor List
• Natural Environments Worksheet (pdf)