Audiology
Authorizations/Approvals
- Request for prior approval high intensity services State form 54389
- Prior approval request form State form 51311 (fill-in)
- Final AT policy and form State form 50881
Assessment Team
- Indiana First Steps family summary (Sample)
- Indiana First Steps multidisciplinary assessment report (Sample report)
- Documentation of informed clinical opinion
Eligibility Determination
- Medical health summary State Form 53091
- First Steps Part C eligibility determination statement State form 50054
- Documentation of team discussion State form 51928
Exit Summary
- Exit summary State form 51310
- Exit summary (Spanish) State form 51428
- Child outcomes skill inventory - Exit state form 55620
Family Information Update
- Family information update State form 51358
First Steps
- Changes to the IFSP State form 51841
- Family information update State form 51358
- First Steps medical insurance consent State form 51308
- Indiana individualized family service plan to enhance the capacity of families to meet the special needs of their child State form 46514
- Medical insurance supplement State form 51309
- Provider summary of service form
Intake
- First Steps enrollment form State form 54645
Income and Insurance
- Hoosier Healthwise enrollment checklist
- Medical insurance consent State form 51308
- Medical insurance supplement State form 5130
- Cost participation expenses worksheet State form 51359
- Cost participation co-payment form State form 51361
- Family information update State form 51358
- Insurance issue form State form 54962
IFSP (Initial or Annual)
- Annual IFSP checklist State form 51919
- Annual preparation checklist State form 53976
- Changes to the IFSP State form 51841
- Confirmation of start of IFSP services State form 55678
- Documentation of team discussion State form 51928
- Family assessment pilot form final
- IFSP pilot form final
- IFSP, spanish version, Initial contact checklist State form 53977
- Outcome review State form 51838
- Reason for delay of IFSP, revised State form 51312
- Request for authorization/meeting minutes State form 51839
- Service coordinator visit checklist State form 53978
- Request for change or addition in service with ED team response State form 54960
Six Month IFSP Review Packet
- Quarterly IFSP review cover sheet State form 51840
- Outcome review State form 51838
- Request for authorization/meeting minutes State form 51839
Changes to the IFSP Packet
- Service change to the IFSP checklist State form 51921
- Documentation of team discussion State form 51928
- Changes to the IFSP State form 51841
Progress Reports
- Progress report form 1 outcome
- Progress report form 2 outcome
- Progress report form 3 outcome
- Progress report form 4 outcome
- Progress report form additional outcome
Provider Enrollment and Credentialing
Referral
- Medical provider referral form State form 53097
- Referral form (sample)
Releases
- Documentation of receipt of rights/consent to proceed/permission to access State form 51842
- Authorization to release and share medical information State form 55164
- General reciprocal consent to release and share information State form 51675
- Electronic database release (CRO 1) State form 55163
- Provider reciprocal consent to release and share information State form 47960
Termination
- Ongoing record termination State form 52001
Transfer to another County
- Documentation of transfer to another county State form 52000
Transition Forms
- Transition plan instructions
- First Steps transition meeting minutes State form 51674
- Individualized family transition plan State form 51672
- Family information update State form 51358
- Request for authorization for transition meeting / transition checklist State form 51670
- Transition meeting notification State form 51671
- First Steps 30 month notice to local educational agency State form 51673