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ERIE COUNTY EARLY INTERVENTION INTAKE FAX FORM 2026
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- Click ‘Get Form’ to open the ERIE COUNTY EARLY INTERVENTION INTAKE FAX FORM in the editor.
- Begin by filling out the Demographic Information section. Enter the child's name, birth last name, date of birth, race, primary language, living situation, age, and Social Security Number. Ensure accuracy as this information is crucial for processing.
- Next, provide details about the parent or guardian. Include their name, phone numbers (home and office), and emergency contact information. This ensures that communication remains seamless.
- In the Insurance Information section, indicate whether there is insurance coverage or if you are applying under Medical Assistance. Fill in any relevant policy details if applicable.
- Complete the Referral Details by specifying the referral source and reason for referral. It's important to clarify if the parent or guardian has been informed about this referral.
- Finally, address Diagnosis Details by selecting any relevant conditions and confirming if a screening has been conducted. Indicate how documentation can be obtained for records.
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What is the fax number for early intervention in NYC?
If you think your child has a developmental delay and needs help, you can make a referral to EI by calling 311 and asking for Early Intervention, or completing the New York City Intervention Referral form and faxing it to (347) 396-8801.
How to apply for early intervention in NYC?
Start by talking with your doctor, nurse, or clinic about early intervention. If you dont get a referral from your health care provider, contact the states early intervention center. The state will assign a service coordinator as the point person for your child.
What is the fax number for Early Intervention NYC?
Referring Children to EI If you think your child has a developmental delay and needs help, you can make a referral to EI by calling 311 and asking for Early Intervention, or completing the New York City Intervention Referral form and faxing it to (347) 396-8801.
What is the fax number for Medicaid in NY?
Medicaid clients who have case changes that require additional documentation should use the MAP-751W form below. The documentation should also be submitted with the MAP-751W. The form can be submitted via fax to 917-639-0837.
What is the first steps Early Intervention program in Indiana?
First Steps is Indianas early intervention program that provides services to infants and toddlers from birth to third birthday who have developmental delays or disabilities.
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Jun 11, 2025 A service coordinator makes the first visit to explain the program and to have the forms signed. Fax: (716) 858-8701. All ECDOH Locations.Read more