Healthcare IFSP Signature Pages

INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) - SIGNATURE PAGES

Child / Family Information

Child Name:

Date of Birth:    Gender:

Primary Phone:    Emergency Contact:    Phone:

Health & Medical History

IFSP Team Participants

Service Coordinator:    Agency:

Family Representative:    Relationship:

Other Participants (Name / Role / Agency):

Consent to IFSP and Services

I hereby consent to the IFSP as developed on: . I acknowledge that the IFSP describes the early intervention services recommended for this child, the projected frequency and location of services, and measurable outcomes to be addressed.

I consent to the following services as listed on the IFSP (check all that apply) and authorize necessary exchanges of records for coordination of care:

Physical Therapy — Provider:

Occupational Therapy — Provider:

Speech-Language Therapy — Provider:

Special Instruction / Developmental Intervention — Provider:

Information Release & Privacy Acknowledgment

I authorize the exchange of information among the agencies and providers participating in the IFSP for the purpose of planning and delivering early intervention services. This authorization includes, but is not limited to, educational records, health records, service notes, and assessments necessary to provide coordinated services.

I understand that signing this document authorizes release of information for coordination of services and that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Revocation must be submitted in writing to the service coordinator.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding the use and disclosure of my child's protected health information.

Procedural Safeguards and Copy of IFSP

I acknowledge that I have been informed of my rights under the early intervention program, including the right to participate in meetings, the right to prior written notice, and the right to dispute resolution and mediation procedures.

I acknowledge receipt of a copy of the IFSP today.

Additional Family Statements

By signing below I affirm that I have participated in the development of the IFSP, that the content accurately reflects the plan discussed with me, and that I have been informed of my rights and options regarding services. I may withdraw consent for services at any time by providing written notice to the service coordinator, subject to program policies regarding timely notice and transition planning.

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