InfantVA - Provider Information

Practice Manual and Forms

Family Safeguards
- Notice of Child and Family Rights in the Infant & Toddler Connection of Part C Early Intervention System [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Strengthening Partnerships [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
Practice Manual 8-2011

Information for New Providers
Forms
- Child Indicator Summary Form
- Confirmation of IFSP Schedule (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Confirmation of Scheduled Meetings/Activities (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Declining EI Services (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Declining Private Insurance (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Eligibility Determination (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Family Cost Share - Agreement Form (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Family Cost Share - Appeal Form (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Family Cost Share - Facts (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Family Cost Share - Fee Scale [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)] ]
- Hearing Screening Instructions Hearing Form (Word)
- IFSP – electronic (Word 2003) (Word 2007)
- IFSP – hand (Word 2003) (Word 2007) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Individual Child Data Form and Instructions
- Initial EI Service Coordination Plan form (06-13-11) (Word)
- Intervention Activity Note (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Medicaid Appeal Request - DMAS
- Medicaid Notice of Action Letter (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Notice and Consent for Assessment for Service Planning (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Notice and Consent to Determine Eligibility (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Notification to DMAS: Family Declining to Bill Private Insurance
- Parental Prior Notice (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Referral - Non-Physician (Word)
- Referral - Physician (Word) Instructions
- Surrogate Parent Identification of Need (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Vision Screening Instructions Vision Form (Word)
Professional Development Procedures
Letters
- Acknowledgement to Referral Source (Word)
- IFSP Summary Letter (Word)
- IFSP Review Summary Letter (Word)
- Notice to Biological Adoptive Parent (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Physician Certification Letter (Word) - sample
  - Physician Certification including Health Indicator Questions (06-13-11) (Word)
  - Health Indicator Questions MD Communication (06-13-11) (Word)
- Surrogate Parent Appointment (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
- Surrogate Parent Termination (Word) [Farsi (Word)] [Korean (Word)] [Spanish (Word)] [Vietnamese (Word)]
Q & A Documents
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