Wednesday, July 30, 2014

Standardized Referral Form for Early Intervention (From HFS)

07/30/14

Informational Notice

To: All Medical Assistance Providers

Re: Standardized Referral Form for Early Intervention

Objective Developmental Screening

An objective developmental screening using a recognized instrument is a structured evaluation of a child's development (i.e., physical, language, intellectual, social-emotional) and is performed by the primary care provider (PCP) or other trained provider. Children should be referred for a comprehensive evaluation and services as an outcome of the well-child visit or as indicated by the results of an objective developmental screening tool. Please refer to the Handbook for Providers of Healthy Kids Services (pdf) Section HK-203.5 Developmental Screening and Assessment for more information.

Referrals

When a child, three years of age or younger, needs a comprehensive evaluation for suspected developmental delay, a referral to the Department of Human Services’ (DHS) Early Intervention (EI) program, Child and Family Connections (CFC) offices can be made using the “Standardized Illinois Early Intervention Referral Form” Form 650, available on HFS’ Medical Program Forms webpage. Search either alphabetically or by form number. The form can be printed or saved to your computer for use. The form includes a hyperlink to an online tool to look up the CFC office(s) serving your area. A list of CFC offices by the counties they serve is attached to this Notice for reference.

The advantages of using the standardized referral form are:
  1. The form secures consent that meets Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA) requirements;
  2. The form initiates a process whereby EI CFC office staff send information back to the referring provider about the outcome of the referral; and
  3. The referral form is sent from the provider directly to the local EI CFC office thereby removing the burden on the family to contact EI.
Providers are strongly encouraged to use the standardized referral form to ensure transfer of a consistent set of information that is actionable by the EI CFC office staff.

The referral form is paired with a standardized “Illinois Early Intervention Program Referral Fax Back Form” Form 652 (available on the Medical Program Forms webpage) to assure that the referring provider, with proper consent secured using the referral form, receives information about the outcome of the referral. EI CFC staff complete Part 1 of 2 after they contact the family to inform the referring provider about the outcome of the contact. When EI CFC staff cannot reach the family, providers should follow-up with the family to encourage them to contact their local EI office. Part 2 of 2 is completed by EI CFC staff after the child receives an assessment to inform the provider about the outcome.

Currently, these forms are faxed between the provider and the local EI CFC office. In development is an online referral system whereby providers may send referral information electronically to the local EI CFC office. The referring provider will be notified via e-mail that outcome information is available. Information about this developing process will be shared at a later date.

The forms and communication processes were tested through a pilot project conducted by HFS, DHS and the Illinois Chapter, American Academy of Pediatrics (ICAAP). The project was funded by The Commonwealth Fund and administered by the National Academy for State Health Policy.

Providers wishing to receive e-mail notification when new provider information is posted by the Department may register on the HFS Provider Releases and Bulletins E-mail Notification Request webpage.

Theresa A. Eagleson, Administrator
Division of Medical Programs

Child and Family Connections Listing of Illinois
Illinois Department of Human Services- Bureau of Early Intervention Early Intervention
Revised – June 2014 

CFC CFC Site Address, Phone, Fax & Toll Free Numbers Serving County(s) and/or Zip Codes
1 Child & Family Connections
Access Services of Northern Illinois
1752 Windsor Rd., Ste. 102/ PO Box 16390
Loves Park, IL  61132-6390
815-654-6170
Fax:  815-654-6197
Toll Free #:  800-921-0094
Boone
Bureau 
Marshall
Ogle    
Putnam
Winnebago
2 Child & Family Connections
Lake County Health Department
3010 Grand Ave., 2nd Floor
Waukegan, IL  60085
847-377-8900
Fax:  847-377-8939
Toll Free #: 888-539-3033
Lake
3 Child & Family Connections
Regional Office of Education for Carroll, Jo Daviess, & Stephenson Co.
27 S. State Avenue, Suite 101
Freeport, IL 61032-4210
815-297-1041
Fax:  815-297-9032
Toll Free #:  888-297-1041
Carroll              
DeKalb
Jo Daviess
Lee      
Stephenson      
Whiteside
4 Child & Family Connections
DayOne Network
1551 E. Fabyan Pkwy.
Geneva, IL 60134
630-879-2277
Fax:  630-761-9810
Toll Free #: 888-282-0997
Kane                
Kendall
5 Child & Family Connections
PACT, Inc.
750 Warrenville Rd., Suite 300
Lisle, IL  60532
630-493-0400
Fax: 630-493-1995
Toll Free #: 800-637-7181
DuPage County including the following Cook County zip codes:
60103 and 60126 
6 Child & Family Connections
Clearbrook Center
1835 W. Central Rd.
Arlington Heights, IL  60005
847-385-5070
Fax: 847-385-7260
Toll Free #: 800-585-1953
*Cook County North Suburban including the following zip codes:
60004
60005
60006
60007
60008
60010
60015
60016
60018
60022
60025
60026
60029
60035
60043
60053
60056
60062
60067
60068
60070
60074
60076
60077
60082
60089
60090
60091
60093
60095
60106
60107
60120
60133
60143
60149
60157
60169
60172
60173
60192
60193
60194
60195
60196
60201
60202
60203
60204
60666
60712
60714
7 Child & Family Connections
Suburban Access, Inc
One Westbrook Corporate Center, Suite 640
Westchester, IL 60154
708-449-0625
Fax: 708-449-7071
Toll Free #: 888-566-8228
*Cook County Central Suburban including the following zip codes:
60104
60130
60131
60141
60153
60154
60155
60160
60162
60163
60164
60165
60171
60176
60301
60302
60303
60304
60305
60402
60513
60521
60525
60526
60527
60534
60546
60558
60706
60707
60804
8 Child & Family Connections
Easter Seals Society of Metropolitan Chicago
9455 S. Hoyne Ave.
Chicago, IL 60643
773-233-1799
Fax: 773-233-2011     239-6229
Toll Free #: 866-266-7167
*Cook County Chicago Southwest including the following zip codes:
60620
60628
60629
60633
60638
60643
60652
60655
60805
60827
*This CFC serve those families who reside within the City of Chicago when the zip codes cross the city lines.
9 Child & Family Connections
Fantus Health Center
1901 W. Harrison St., Rm. A2101
Chicago, IL 60612
312-864-6575
Fax: 312-864-9332
Toll Free #: 888-816-3188
*Cook County Chicago Central/ West including the following zip codes:
60601
60602
60603
60604
60605
60606
60607
60608
60612
60616
60623
60624
60632
60644
60661
10 Child & Family Connections
La Rabida Children’s Hospital
1525 E. 55th St., Suite 203
Chicago, IL 60615
773-324-7434
Fax: 773-324-7469
Toll Free #: 800-862-1912
*Cook County Chicago Southeast including the following zip codes:
60609
60615
60617
60619
60621
60636
60637
60649
60653
11 Child & Family Connections
945 W. George St., Suite 300
Chicago, IL  60657
312-942-7800
Fax: 312-942-7811
Toll Free #: 800-289-7990
*Cook County Chicago North including the following zip codes:
60610
60611
60613
60614
60618
60622
60625
60626
60630
60631
60634
60639
66040
60641
60642
60645
60646
60647
60651
60654
60656
60657
60659
60660
12 Child & Family Connections
Easter Seals Society of Metropolitan Chicago
17300 S. Ozark Ave. - North Bldg.
Tinley Park, IL 60477
708-429-8231
Fax: 708-429-8246
Toll Free #: 800-597-7798
*Cook County South Suburban including the following zip codes:
60406
60409
60411
60415
60417
60419
60422
60423
60425
60426
60428
60429
60430
60439
60438
60443
60445
60448
60449
60452
60453
60455
60456
60457
60458
60459
60461
60462
60463
60464
60465
60466
60467
60469
60471
60472
60473
60475
60476
60477
60478
60480
60482
60487
60491
60501
60803
13 Child & Family Connections
Reg. Office of Education  # 26
1301 N. Main St., Suite 3
Monmouth, IL 61462
309-734-3336
Fax: 309-734-1145
Toll Free #: 866-426-2160             
Fulton
Hancock
Henderson
Knox
McDonough
Mercer
Rock Island
Schuyler
Warren
14 Child & Family Connections
3000 W. Rohmann Ave.
West Peoria, IL 61604
309-672-6360
Fax: 309-681-0190
Toll Free #: 888-482-4300
Henry
Peoria
Stark
Tazewell
Woodford
15 Child & Family Connections
Services of Will, Grundy, & Kankakee Counties, Inc.
2300 Glenwood Ave.
Joliet, IL 60435
815-730-2617
Fax: 815-730-2650
Toll Free #: 888-329-0633
Grundy
Kankakee
LaSalle
Will
16 Child & Family Connections
103 S. Country Fair Dr.
Champaign, IL 61821
217-693-7958
Fax:  217-693-7967
Toll Free #: 800-877-1152
Champaign
Ford
Iroquois
Livingston
McLean
Vermilion
17 Child & Family Connections
ROE of Adams/Pike Counties
510 Maine St., Suite 615
Quincy, IL 62301
217-222-9592
Fax: 217-222-9593
Toll Free #: 888-222-9592
Adams
Brown
Calhoun
Cass
Greene
Jersey
Morgan
Pike
Scott
18 Child & Family Connections
Sangamon Co. Public Health Department
2833 South Grand Ave., East
Springfield, IL  62703
217-535-3100
Fax: 217-793-3991
Toll Free #: 888-217-3505
Logan
Mason
Menard
Sangamon
19 Child & Family Connections
Macon County Community Mental Health Board
132 S. Water St., Suite 604
Decatur, IL 62523
217-423-6199
Fax: 217-233-7028
Toll Free #: 800-758-2705
Clark
Coles
Cumberland
DeWitt
Douglas
Edgar
Macon
Moultrie
Piatt
Shelby
20 Child & Family Connections
ARC Community Support Systems
1901 S. 4th St., Suite 209
Effingham, IL. 62401
217-347-5601
Fax: 217-347-5119
Toll Free #: 888-459-5437
Bond
Christian
Clay
Crawford
Effingham
Fayette
Jasper
Lawrence
Macoupin
Montgomery
Richland
21 Child & Family Connections
Regional Office of Education #13
4 Eagle Center, Suite 4
O’Fallon, IL  62269
618-622-6581
Fax: 618-622-8662
Toll Free #: 888-594-8364
Madison
Monroe
Randolph
St. Clair
22 Child & Family Connections
Regional Office of Education #13
101 S. Lincoln Blvd.
Centralia, IL 62801
618-532-4919
Fax: 618-532-0856
Toll Free #: 800-661-0900
Clinton
Franklin
Jefferson
Marion
Washington
Williamson
23 Child & Family Connections
Wabash & Ohio Valley Special Education Dist.
800 S. Division St./PO Box 320
Norris City, IL 62869
618-378-2131
Fax: 618-378-3127
Toll Free #: 800-463-2759
Edwards
Gallatin
Hamilton
Saline
Wabash
Wayne
White
24 Child & Family Connections
Archway, Inc.
2751 W. Main St./ PO Box 1180
Carbondale, IL 62901-1180
618-529-3147
Fax: 618-549-8137
Toll Free #: 888-340-6702
Alexander
Hardin
Jackson
Johnson
Massac
Perry
Pope
Pulaski
Union
25 Child & Family Connections
Options & Advocacy for McHenry Co.
365 Millennium Dr., Suite A
Crystal Lake, IL 60012
815-477-4720
Fax/TDD: 815-788-0704
Toll Free #: 888-376-8828
McHenry

Special Notes:
* When a zip code crosses county lines, Cook Child and Family Connections will serve the portion that falls within Cook County.
** Toll free numbers are only accessible within Illinois. All other states must use the local number listed.
*** CFCs that are Satellite Offices- CFC 27 reports to CFC 17, CFC 28 reports to CFC 14 & CFC 29 reports to CFC 1

If you have any questions or have changes regarding this listing, please contact the DHS, Bureau of Early Intervention at 217-782-1981.

If you would like more information on Early Intervention, please visit the DHS for Early Intervention Providers webpage and review the brochures and manuals sections.