Healthcare IFSP Form

Healthcare IFSP Form

Child and Primary Information

Child Name:    Date of Birth:

Gender:    Preferred Language:

Family / Emergency Contacts

Relationship:    Phone:

Emergency Phone:    Relationship:

Insurance and Coverage

Policy Number:    Group Number:

Medical History

Immunizations up to date: Yes    Immunization exemption claimed: Yes

Present Levels of Development

Describe the child's current functional performance, strengths, and areas of need. Use measurable descriptions where possible.

IFSP Outcomes, Services, and Service Delivery

Each listed outcome must be measurable, specify expected criteria, identify services to achieve the outcome, designate the service provider, frequency, location, projected start date, and anticipated date for review.

Service Type:    Provider:

Frequency:    Location:

Projected Start Date:    Anticipated Review Date:

Service Type:    Provider:

Frequency:    Location:

Projected Start Date:    Anticipated Review Date:

Health-Related Services and Supports

Identify health-related services the child requires as part of the IFSP, including skilled nursing, feeding supports, medication administration, assistive technology, and behavior supports.

Skilled Nursing    Feeding / Swallowing Supports    Medication Administration    Assistive Technology    Behavioral Support

Transition Planning

Anticipated Transition Date:

Consent, Authorization, and Acknowledgment

By signing below, I authorize the provision of early intervention services identified in this IFSP. I understand services will be provided by qualified personnel and that information in this form may be shared with those providers directly responsible for carrying out the IFSP. I acknowledge that I have been given the opportunity to participate in development of the IFSP, to receive a copy of the IFSP, and to ask questions about proposed services and timelines.

I further authorize the release of relevant health and educational information among the providers listed in this plan for the purpose of coordination, service delivery, and continuity of care. This authorization permits only information necessary to implement the IFSP and does not authorize the disclosure of unrelated records.

I understand I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance upon it. I understand that refusal to sign or later revocation of authorization may affect the delivery of certain services.

Does this authorization have no expiration (check if applicable)?

I acknowledge that I have received or been offered information regarding privacy practices and the use and disclosure of protected health information necessary to provide services under this IFSP. I understand my rights to inspect and request amendment of records as provided by law.

Consent for telehealth services (if applicable): I consent to receive telehealth services when clinically appropriate and understand associated privacy and technical limitations.

Signatures and Certification

The undersigned certifies that the information contained in this IFSP is complete and accurate to the best of their knowledge. Signing below affirms informed consent to the plan as described and responsibilities for participation and coordination.

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