Forms

Below is an alphabetic list of documents used by Child & Family Connections Staff with or on behalf of an Early Intervention family. If you require assistance with any of these documents, please contact Jenni Grissom at 217/524-1596.

• 0-5 Child Find Screening Data Collection Form & Directions
• Child and Family Connections Acknowledgement and Notice of Provisional Provider Status - English (pdf) - Child and Family Connections Acknowledgement and Notice of Provisional Provider Status - Spanish (pdf)
• Child and Family Connections Acknowledgement and Notice of Social Security Disclosure - English (pdf) - Child and Family Connections Acknowledgement and Notice of Social Security Disclosure - Spanish (pdf)
• Child and Family Connections Acknowledgement of Receipt of Notices - English (pdf) - Child and Family Connections Acknowledgement of Receipt of Notices - Spanish (pdf)
• Child and Family Connections Acknowledgement to Decline Exemption - English (pdf) - Child and Family Connections Acknowledgement to Decline Exemption - Spanish (pdf)
• Child and Family Connections Assistive Technology Approval Request (pdf)
• Child and Family Connections Change of Insurance Notification (pdf)
• Child and Family Connections Consent For Release of Information - English (pdf) - Child and Family Connections Consent For Release of Information - Spanish (pdf)
• Child and Family Connections Consent For Release of Information for Children with Identified Hearing Loss - English (pdf) - Child and Family Connections Consent For Release of Information for Children with Identified Hearing Loss - Spanish (pdf)
• Child and Family Connections Consent to Use Private Insurance/Healthcare Plan Benefits and Assignment of Rights - English (pdf) - Child and Family Connections Consent to Use Private Insurance/Healthcare Plan Benefits and Assignment of Rights - Spanish (pdf)
• Child and Family Connections Consent to Use Private Insurance/Healthcare Plan Benefits and Assignment of Rights for Specific Services - English (pdf) - Child and Family Connections Consent to Use Private Insurance/Healthcare Plan Benefits and Assignment of Rights for Specific Services - Spanish (pdf)
• Child and Family Connections Development Justification To Change Frequency, Intensity and/or Location or Authorized Services Form and Provider Guidelines and Worksheet (pdf)
• Child and Family Connections Family Participation Fee Credit Request (pdf)
• Child and Family Connections Family Participation Fee Exemption Request - English (pdf) - Child and Family Connections Family Participation Fee Exemption Request - Spanish (pdf)
• Child and Family Connections Fax Cover Sheet for Insurance Benefits Verification Requests/Updates (pdf)
• Child and Family Connections Intake/Social History Summary Sheet (pdf)
• Child and Family Connections Nepotism Disclosure Form (pdf)
• Child and Family Connections Notice of Confidentiality Practices - English (pdf) - Child and Family Connections Notice of Confidentiality Practices - Spanish (pdf)
• Child and Family Connections Notice of System of Payments and Fees - English (pdf) - Child and Family Connections Notice of System of Payments and Fees - Spanish (pdf)
• Child and Family Connections Notice to Use Public Benefits-All Kids Enrolled or Potentially Eligible for All Kids - English (pdf) - Child and Family Connections Notice to Use Public Benefits-All Kids Enrolled or Potentially Eligible for All Kids - Spanish (pdf)
• Child and Family Connections Parental Consent and Ability to Decline Services - English (pdf) - Child and Family Connections Parental Consent and Ability to Decline Services - Spanish (pdf)
• Child and Family Connections Pre-Billing Insurance Waiver Request (pdf)
• Child and Family Connections Provisional Provider Authorization Request (pdf)
• Child and Family Connections Provisional Provider Request (pdf)
• Child and Family Connections Tax Savings Account Information Sheet - English (pdf) - Child and Family Connections Tax Savings Account Information Sheet - Spanish (pdf)
• Child and Family Connections Waiver of Written Prior Notice - English (pdf) - Child and Family Connections Waiver of Written Prior Notice - Spanish (pdf)
• Early Intervention to Early Childhood Transition Tracking Procedures & Form (pdf) - r05/2016
• Illinois Early Intervention Services System Family Participation Fees Program Fact Sheet - English (pdf) - Illinois Early Intervention Services System Family Participation Fees Program Fact Sheet - Spanish (pdf) (Updated every July)
• Illinois Early Intervention Services System Family Participation Fees Payment Agreement - English (pdf) - Illinois Early Intervention Services System Family Participation Fees Payment Agreement - Spanish (pdf)
• Individualized Family Service Plan Meeting Attendance Waiver for Audiologists (pdf)
• Natural Environments Justification Worksheet & Requirements (pdf)
• Request for Due Process Hearing Officer - English (pdf) - Request for Due Process Hearing Officer - Spanish (pdf)
• Request for Investigation of State Complaint - English (pdf) - Request for Investigation of State Complaint - Spanish (pdf)
• Request for Mediation - English (pdf) - Request for Mediation - Spanish (pdf)
• Screening Device for Determining Family Fees and Eligibility for All Kids and DSCC - English (pdf) - Screening Device for Determining Family Fees and Eligibility for All Kids and DSCC - Spanish (pdf)

These are Healthcare and Family Services forms. Click on links to view and print the forms.

• Standardized Illinois Early Intervention Referral Form (HFS 650) - R03-2018
• Illinois Early Intervention Referral Form Fax Back Form (HFS 652)- R03-2018

If you need additional information regarding these CFC-related forms, please contact the Bureau of Early Intervention at 217/782-1981.

Rev. 02/2019