Free 51670.FH11 - Indiana

REQUEST FOR AUTHORIZATION FOR TRANSITION MEETING / TRANSITION CHECKLIST
State Form 51670 (R3 / 3-07) / BCD 0103

The State of Indiana requires all children exiting First Steps to have a 90-270 day Transition Meeting. The purpose of this meeting is to discuss and plan for the childs next placement/options. When developing this plan it is important to involve the current team of providers as well as potential providers or agency representatives. This meeting should include discussion around equipment needs, therapy needs, future placement options, summer options, enrollment criteria, eligibility criteria, timelines, and any necessary information.
Name of child Date of birth (month, day, year)

Date of Transition Meeting (month, day, year)

PROVIDER

AGENCY

DISCIPLINE / SPECIALTY

TIME NEEDED

LOCATION Off Site On Site Off Site On Site Off Site On Site Off Site On Site Off Site On Site

AUTHORIZATION NUMBER

Note: Off Site = natural environment for the child. For settings other than the childs natural environment, an On Site authorization should be generated.
Signature of Service Coordinator Date (month, day, year)

You must include each of the items listed below in order for the SPOE to generate your transition meeting billing authorization. Incomplete forms will be returned.
DATE COMPLETED ITEMS INCLUDED

Request for Authorization Form / Transition Checklist 30 Month Notice to Local Education Agency (LEA) 30 Month Reciprocal Release Transition Meeting Notification (Written prior notice) Individualized Family Transition Plan (pages 1 & 2) Transition Meeting Minutes