Free 51929.FH11 - Indiana

PHYSICIANS HEALTH SUMMARY FIRST STEPS EARLY INTERVENTION SYSTEM CHILDRENS SPECIAL HEALTH CARE SERVICES
State Form 51929 (R2 / 1-07) / BCD 0119

Division of Disability and Rehabilitative Services Effective May 01, 2006 Your patient is currently in the evaluation process for eligibility for CSHCS and/or early intervention services under Part C of the Individuals with Disabilities Education Act (IDEA). The health summary request is an initial step in this process. Your participation is requested by completing and returning this form. If you have questions, please contact the Intake / Service Coordinator listed below. Your participation in this activity is greatly appreciated. IDENTIFYING INFORMATION
Name of child Name of parent / guardian Reason(s) for referral Date of birth (month, day, year) County

CURRENT HEALTH STATUS
Diagnosed medical condition (please specify) Current medications Medical precautions Physical status Please note any concerns with vision or hearing Are immunizations current? ICD codes (highest specificity)

Yes

No

DIAGNOSED PHYSICAL OR MENTAL CONDITION WITH A HIGH PROBABILITY OF DELAY Please check all that apply. Please use code with highest available specificity. Chromosomal abnormalities or genetic disorder Neurological disorder Congenital Malformation Sensory impairments, including vision or hearing Severe toxic exposure including prenatal exposure Low birth weight < 1500 grams Neurological abnormality in the newborn period
Please indicate specific concerns or comments related to the childs development below.

ICD Code:_______________ ICD Code:_______________ ICD Code:_______________ ICD Code:_______________ ICD Code:_______________ ICD Code:_______________ ICD Code:_______________

I recommend and authorize a developmental assessment be provided to the child to rule out a developmental delay in one or more of the following developmental domains under V 79.3: Cognitive development Adaptive development Physical development (including vision or hearing) Communication development Social or emotional development

Signature of parent (Signature on this form authorizes First Steps to provide a comprehensive developmental assessment to determine the level of the childs development and to identify if a developmental delay is present.)

Date (month, day, year)

Signature of physician

Date (month, day, year)

Name of physician (please print)

Telephone number

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Please return to: Telephone number Fax number

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DISTRIBUTION:

Original - SPOE; Copy - Primary care physician and family